Provider Demographics
NPI:1518953447
Name:HANES, TRACI PAGE (CRNA)
Entity Type:Individual
Prefix:MS
First Name:TRACI
Middle Name:PAGE
Last Name:HANES
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:TRACI
Other - Middle Name:MICHELLE
Other - Last Name:PAGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:145 KIMEL PARK DR STE 120
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-6983
Mailing Address - Country:US
Mailing Address - Phone:336-768-3212
Mailing Address - Fax:336-768-9019
Practice Address - Street 1:145 KIMEL PARK DR STE 120
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103
Practice Address - Country:US
Practice Address - Phone:336-768-3212
Practice Address - Fax:336-768-9019
Is Sole Proprietor?:No
Enumeration Date:2005-09-26
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC151906163W00000X
NC070424367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8052050Medicaid
SCNAN498Medicaid
NC2606231AMedicare PIN