Provider Demographics
NPI:1912201740
Name:BRUNETTE, TRACY MICHELLE (NP)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:MICHELLE
Last Name:BRUNETTE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:MICHELLE
Other - Last Name:EDWARDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:320 SE BAKER ST
Mailing Address - Street 2:
Mailing Address - City:MCMINNVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97128-6038
Mailing Address - Country:US
Mailing Address - Phone:503-474-3600
Mailing Address - Fax:503-474-3601
Practice Address - Street 1:320 SE BAKER ST
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:OR
Practice Address - Zip Code:97128-6038
Practice Address - Country:US
Practice Address - Phone:503-474-3600
Practice Address - Fax:503-474-3601
Is Sole Proprietor?:No
Enumeration Date:2011-01-09
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201050167363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500635439Medicaid
ORR170803Medicare PIN