Provider Demographics
NPI:1346295649
Name:NIMMERRICHTER-BURGESS, TRACY
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:NIMMERRICHTER-BURGESS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:316W BOONE AVE 757
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99201-2364
Mailing Address - Country:US
Mailing Address - Phone:509-868-0876
Mailing Address - Fax:509-385-0670
Practice Address - Street 1:830 SE IRELAND ST
Practice Address - Street 2:
Practice Address - City:OAK HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98277-5502
Practice Address - Country:US
Practice Address - Phone:360-675-7678
Practice Address - Fax:360-279-0614
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-24
Last Update Date:2015-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00031197207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1103449Medicaid
WA1103449Medicaid
E87965Medicare UPIN