Provider Demographics
NPI:1790039824
Name:RODDEN-LARSON, TRACY MARIE
Entity Type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:MARIE
Last Name:RODDEN-LARSON
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 1:60 HALL ST
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-4828
Mailing Address - Country:US
Mailing Address - Phone:907-452-6434
Mailing Address - Fax:907-451-6598
Practice Address - Street 1:60 HALL ST
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-4828
Practice Address - Country:US
Practice Address - Phone:907-452-6434
Practice Address - Fax:907-451-6598
Is Sole Proprietor?:No
Enumeration Date:2012-10-26
Last Update Date:2012-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator