Provider Demographics
NPI:1447206388
Name:BRETL, TRACY LYNN (DO)
Entity Type:Individual
Prefix:DR
First Name:TRACY
Middle Name:LYNN
Last Name:BRETL
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 1:6793 N GREEN BAY AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-3422
Mailing Address - Country:US
Mailing Address - Phone:414-351-1844
Mailing Address - Fax:414-351-0678
Practice Address - Street 1:6793 N GREEN BAY AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53209-3422
Practice Address - Country:US
Practice Address - Phone:414-351-1844
Practice Address - Fax:414-351-0678
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2012-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI31707-021204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30055700Medicaid
WIF32099Medicare UPIN
WI30055700Medicaid