Provider Demographics
NPI:1568761658
Name:LONG, TRACY
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9499 W CHARLESTON BLVD
Mailing Address - Street 2:STE 200
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89117-7150
Mailing Address - Country:US
Mailing Address - Phone:702-933-9393
Mailing Address - Fax:702-933-6789
Practice Address - Street 1:9499 W CHARLESTON BLVD
Practice Address - Street 2:STE 200
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89117-7150
Practice Address - Country:US
Practice Address - Phone:702-933-9393
Practice Address - Fax:702-933-6789
Is Sole Proprietor?:No
Enumeration Date:2011-03-15
Last Update Date:2011-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other