Provider Demographics
NPI:1497424832
Name:RODRIGUEZ, TRACY (NP)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1408 SUNSET DR
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-4600
Mailing Address - Country:US
Mailing Address - Phone:903-316-1485
Mailing Address - Fax:
Practice Address - Street 1:6210 S BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-4413
Practice Address - Country:US
Practice Address - Phone:903-579-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-09
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1032212363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner