Provider Demographics
NPI:1720188022
Name:MOORE, TRACEY D (NP)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:D
Last Name:MOORE
Suffix:
Gender:F
Credentials:NP
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Mailing Address - Street 1:1241 W MINERAL AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LITTLETON
Mailing Address - State:CO
Mailing Address - Zip Code:80120-5685
Mailing Address - Country:US
Mailing Address - Phone:303-759-0854
Mailing Address - Fax:303-759-0864
Practice Address - Street 1:214 E 23RD ST
Practice Address - Street 2:CHEYENNE REGIONAL MEDICAL CENTER, EMERGENCY DEPT.
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-3748
Practice Address - Country:US
Practice Address - Phone:307-634-2273
Practice Address - Fax:307-633-7671
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2009-05-11
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WY175880851363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY123828100Medicaid
CO35177837Medicaid
WY314502OtherBCBS
WYQ72148Medicare UPIN
WYC21298Medicare PIN