Provider Demographics
NPI:1659301471
Name:RODRIGUEZ, TRACI (FNP)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:TRACI
Other - Middle Name:
Other - Last Name:GARCIA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:PO BOX 54136
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79453-4136
Mailing Address - Country:US
Mailing Address - Phone:806-771-1386
Mailing Address - Fax:806-771-1388
Practice Address - Street 1:3516 22ND PL
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79410-1316
Practice Address - Country:US
Practice Address - Phone:806-771-1386
Practice Address - Fax:806-771-1388
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX577500363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP00090182OtherRR MEDICARE
TXP00317552OtherRR MEDICARE
TXP00216190OtherRR MEDICARE
TX124233109Medicaid
TX141133204Medicaid
TX8Y0236OtherBLUE CROSS BLUE SHIELD
TX141133203Medicaid
TXP00216190OtherRR MEDICARE
TX124233109Medicaid
TXP22729Medicare UPIN
TX141133203Medicaid