Provider Demographics
NPI:1700865912
Name:EDWARDS, TRACY (NP)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:
Other - Last Name:CREASER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12 HIGH ST
Mailing Address - Street 2:STE 302
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04240-7634
Mailing Address - Country:US
Mailing Address - Phone:207-795-5750
Mailing Address - Fax:207-795-5649
Practice Address - Street 1:12 HIGH ST
Practice Address - Street 2:STE302
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-7634
Practice Address - Country:US
Practice Address - Phone:207-795-5750
Practice Address - Fax:207-795-5649
Is Sole Proprietor?:No
Enumeration Date:2006-01-16
Last Update Date:2010-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEAP081420363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME260520099Medicaid
METX6481Medicare PIN
MENP1330Medicare ID - Type Unspecified
MEE44037Medicare UPIN