Provider Demographics
NPI:1922280411
Name:METHENY, TRACIE M (CRNA)
Entity Type:Individual
Prefix:
First Name:TRACIE
Middle Name:M
Last Name:METHENY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 711841
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43271-0001
Mailing Address - Country:US
Mailing Address - Phone:304-346-9400
Mailing Address - Fax:304-345-7320
Practice Address - Street 1:1400 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:HURRICANE
Practice Address - State:WV
Practice Address - Zip Code:25526-9202
Practice Address - Country:US
Practice Address - Phone:304-757-1700
Practice Address - Fax:304-757-1732
Is Sole Proprietor?:No
Enumeration Date:2007-11-27
Last Update Date:2013-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV63819367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVP00461235OtherRR MEDICARE
WV002003247OtherMSBCBS
WV27005299703OtherOHIO WORKERS COMP GROUP
WV3810011018Medicaid
WV001706470OtherMSBCBS GROUP
WV0207026000Medicaid
WVDA0096OtherRR MEDICARE
WV1072527OtherBRICKSTREET
WV27005299700OtherBRICKSTREET GROUP
WV002003247OtherMSBCBS
WVP00461235OtherRR MEDICARE