Provider Demographics
NPI:1346264561
Name:HAAS, TRACEY A (DO)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:A
Last Name:HAAS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2710 HARNEY ST STE 202
Mailing Address - Street 2:
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82072-2899
Mailing Address - Country:US
Mailing Address - Phone:307-766-3313
Mailing Address - Fax:
Practice Address - Street 1:2710 HARNEY ST STE 202
Practice Address - Street 2:
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82072-2899
Practice Address - Country:US
Practice Address - Phone:307-766-3313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0056096207Q00000X
TXM0100207Q00000X
WY12820A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX181979903Medicaid
CO0056096OtherMEDICAL LICENSE
TX181979904Medicaid
TXM0100OtherTX STATE LICENSE
WY12820AOtherMEDICAL LICENSE
TXI34766Medicare UPIN