Provider Demographics
NPI:1568523843
Name:CHRISTENSEN, TRACY (OD)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:CHRISTENSEN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16555 77TH CIR N
Mailing Address - Street 2:SUITE 6
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55311-3734
Mailing Address - Country:US
Mailing Address - Phone:210-524-6663
Mailing Address - Fax:210-524-6587
Practice Address - Street 1:8081 WEDGEWOOD LN N
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-9412
Practice Address - Country:US
Practice Address - Phone:763-416-3795
Practice Address - Fax:763-416-3769
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2527152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN535916300Medicaid
MNU59524Medicare UPIN
MN410000658Medicare ID - Type UnspecifiedOD PIN