Provider Demographics
NPI:1629040894
Name:RUSSELL, TRACY LYNNE (MD)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:LYNNE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:LYNN
Other - Last Name:KNIGHTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD,
Mailing Address - Street 1:611 N F ST
Mailing Address - Street 2:STE 201
Mailing Address - City:ABERDEEN
Mailing Address - State:WA
Mailing Address - Zip Code:98520-2667
Mailing Address - Country:US
Mailing Address - Phone:360-533-7677
Mailing Address - Fax:360-533-0470
Practice Address - Street 1:611 N F ST
Practice Address - Street 2:STE 201
Practice Address - City:ABERDEEN
Practice Address - State:WA
Practice Address - Zip Code:98520-2667
Practice Address - Country:US
Practice Address - Phone:360-533-7677
Practice Address - Fax:360-533-0470
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2011-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00046873208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1123256Medicaid
WA1123256Medicaid