Provider Demographics
NPI:1891716700
Name:PURATH, TRACI A (MD)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:A
Last Name:PURATH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5244 ZACHARY DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:WI
Mailing Address - Zip Code:53403-9795
Mailing Address - Country:US
Mailing Address - Phone:262-694-5000
Mailing Address - Fax:262-661-4606
Practice Address - Street 1:565 MILWAUKEE AVE
Practice Address - Street 2:SUITE 2-C
Practice Address - City:BURLINGTON
Practice Address - State:WI
Practice Address - Zip Code:53105-1254
Practice Address - Country:US
Practice Address - Phone:262-694-5000
Practice Address - Fax:262-661-4606
Is Sole Proprietor?:No
Enumeration Date:2006-07-23
Last Update Date:2014-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI40525-0202084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34234000Medicaid
WI34234000Medicaid