Provider Demographics
NPI:1891234761
Name:MATROS, TRACY
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:MATROS
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 1:32500 173RD ST
Mailing Address - Street 2:
Mailing Address - City:PIERZ
Mailing Address - State:MN
Mailing Address - Zip Code:56364-3136
Mailing Address - Country:US
Mailing Address - Phone:320-630-5520
Mailing Address - Fax:
Practice Address - Street 1:32500 173RD ST
Practice Address - Street 2:
Practice Address - City:PIERZ
Practice Address - State:MN
Practice Address - Zip Code:56364-3136
Practice Address - Country:US
Practice Address - Phone:320-630-5520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-13
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCNP 5008363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily