Provider Demographics
NPI:1881661445
Name:COULTER, TRACY R (DPM)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:R
Last Name:COULTER
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N14W23900 STONE RIDGE DR
Mailing Address - Street 2:PROHEALTH CARE MEDICAL ASSOCIATES INC.
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-1135
Mailing Address - Country:US
Mailing Address - Phone:262-574-8000
Mailing Address - Fax:
Practice Address - Street 1:N14W23900 STONE RIDGE DR
Practice Address - Street 2:PROHEALTH CARE MEDICAL ASSOCIATES INC.
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-1135
Practice Address - Country:US
Practice Address - Phone:262-574-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-02
Last Update Date:2012-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI854-025213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43235500Medicaid
WI43235500Medicaid
683750411Medicare PIN
WI82025-003Medicare ID - Type Unspecified