Provider Demographics
NPI:1588652440
Name:PETERSON, TRACY L (CRNA)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:L
Last Name:PETERSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:L
Other - Last Name:HOCKING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:800 EAST CARPENTER STREET
Mailing Address - Street 2:ROOM 2K64
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62769-0001
Mailing Address - Country:US
Mailing Address - Phone:217-525-5643
Mailing Address - Fax:217-544-2521
Practice Address - Street 1:800 EAST CARPENTER STREET
Practice Address - Street 2:ROOM 2K64
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62769-0001
Practice Address - Country:US
Practice Address - Phone:217-525-5643
Practice Address - Fax:217-544-2521
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041269645367500000X
IL209005309367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK10543Medicare PIN