Provider Demographics
NPI:1881858694
Name:TRAUGOTT, TIMOTHY LEE (ACNP)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:LEE
Last Name:TRAUGOTT
Suffix:
Gender:M
Credentials:ACNP
Other - Prefix:
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Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1 FORD PL STE 3A
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-3450
Mailing Address - Country:US
Mailing Address - Phone:313-874-4806
Mailing Address - Fax:313-876-1305
Practice Address - Street 1:15855 19 MILE RD
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038-3504
Practice Address - Country:US
Practice Address - Phone:586-263-2300
Practice Address - Fax:313-876-1305
Is Sole Proprietor?:No
Enumeration Date:2008-07-11
Last Update Date:2023-01-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TX683774164W00000X, 363LA2100X
TXAP116679363L00000X
WI9826363L00000X
IAL154631363L00000X
AZAP11174363L00000X
MI4704351488363L00000X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No164W00000XNursing Service ProvidersLicensed Practical Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1881858694OtherBLUE CROSS BLUE SHIELD
TXP01254148OtherMEDICARE RR
TX282228003Medicaid
WI100096797Medicaid
TX282228002Medicaid
TXP00982598OtherMEDICARE RR
TX845N38OtherBLUE CROSS BLUE SHIELD
TX282228004Medicaid
TXP01094717OtherRR MEDICARE
TX845N38OtherBLUE CROSS BLUE SHIELD
TXP00982598OtherMEDICARE RR
TXP01094717OtherRR MEDICARE
TX282228004Medicaid