Provider Demographics
NPI:1619058740
Name:PETERSON, TRACY M (NURSE PRACTIONER)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:M
Last Name:PETERSON
Suffix:
Gender:F
Credentials:NURSE PRACTIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2901 W KINNICKINNIC RIVER PKWY
Mailing Address - Street 2:SUITE 102
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-3677
Mailing Address - Country:US
Mailing Address - Phone:414-384-6700
Mailing Address - Fax:414-384-3008
Practice Address - Street 1:3077 N MAYFAIR RD STE 305
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53222-4305
Practice Address - Country:US
Practice Address - Phone:414-384-6700
Practice Address - Fax:414-384-3008
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2967-033363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI36011500Medicaid
WI4126880Medicaid