Provider Demographics
NPI:1770197709
Name:MURTHA, TRACY
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:MURTHA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 51
Mailing Address - Street 2:
Mailing Address - City:EAGLE NEST
Mailing Address - State:NM
Mailing Address - Zip Code:87718-0051
Mailing Address - Country:US
Mailing Address - Phone:850-567-0032
Mailing Address - Fax:
Practice Address - Street 1:29 TEDDY BEAR LANE
Practice Address - Street 2:
Practice Address - City:EAGLE NEST
Practice Address - State:NM
Practice Address - Zip Code:87718
Practice Address - Country:US
Practice Address - Phone:850-567-0032
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-08
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer