Provider Demographics
NPI:1528193802
Name:LINDENAU, TRACI ALICE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:TRACI
Middle Name:ALICE
Last Name:LINDENAU
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:TRACI
Other - Middle Name:ALICE
Other - Last Name:FEATHERSTONE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3202 CLAYTON WOODS DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77082-4062
Mailing Address - Country:US
Mailing Address - Phone:801-647-4718
Mailing Address - Fax:
Practice Address - Street 1:3845 W 4700 S
Practice Address - Street 2:
Practice Address - City:TAYLORSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84129-3454
Practice Address - Country:US
Practice Address - Phone:801-840-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6482385-8906363AM0700X
TXPA05225363A00000X
UT6482385-1206363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX212094102Medicaid
TX212094101Medicaid
TX8K5883Medicare PIN
TX212094101Medicaid