Provider Demographics
NPI:1780642744
Name:DOLAN, TRACY J (MS, FNP-C)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:J
Last Name:DOLAN
Suffix:
Gender:F
Credentials:MS, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 ALDER CT
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82009-2528
Mailing Address - Country:US
Mailing Address - Phone:307-214-1386
Mailing Address - Fax:
Practice Address - Street 1:2360 E PERSHING BLVD
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-5356
Practice Address - Country:US
Practice Address - Phone:307-778-7550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2012-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY15902.0190363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYS39328Medicare UPIN
WY20677Medicare ID - Type Unspecified