Provider Demographics
NPI:1528039427
Name:TRACY, ELIZABETH CATHERINE (NP)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:CATHERINE
Last Name:TRACY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:CATHERINE
Other - Last Name:SIWARSKI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP
Mailing Address - Street 1:2130 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:CO
Mailing Address - Zip Code:81401-3834
Mailing Address - Country:US
Mailing Address - Phone:970-252-3123
Mailing Address - Fax:970-252-3208
Practice Address - Street 1:2130 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:CO
Practice Address - Zip Code:81401-3834
Practice Address - Country:US
Practice Address - Phone:970-252-3123
Practice Address - Fax:970-252-3208
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2015-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAPN0991558NP363L00000X
CORN0054045363L00000X
CORXN0101115363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04100095Medicaid
CO22522859Medicaid