Provider Demographics
NPI:1902180748
Name:HOPPER, TRACY D
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:D
Last Name:HOPPER
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 1:35164 S 4465 RD
Mailing Address - Street 2:
Mailing Address - City:VINITA
Mailing Address - State:OK
Mailing Address - Zip Code:74301-6782
Mailing Address - Country:US
Mailing Address - Phone:918-782-1414
Mailing Address - Fax:918-782-1415
Practice Address - Street 1:35164 S 4465 RD
Practice Address - Street 2:
Practice Address - City:VINITA
Practice Address - State:OK
Practice Address - Zip Code:74301-6782
Practice Address - Country:US
Practice Address - Phone:918-782-1414
Practice Address - Fax:918-782-1415
Is Sole Proprietor?:No
Enumeration Date:2011-09-28
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKRC4904171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator