Provider Demographics
NPI:1942453113
Name:DICKERSON, TRACY (CRNA)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:DICKERSON
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 1:1 SEAGATE # 800
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43604-1558
Mailing Address - Country:US
Mailing Address - Phone:419-690-7900
Mailing Address - Fax:419-697-7726
Practice Address - Street 1:2801 BAY PARK DR
Practice Address - Street 2:
Practice Address - City:OREGON
Practice Address - State:OH
Practice Address - Zip Code:43616-4920
Practice Address - Country:US
Practice Address - Phone:419-690-7900
Practice Address - Fax:419-697-7726
Is Sole Proprietor?:No
Enumeration Date:2008-10-31
Last Update Date:2020-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN219439367500000X
OHAPRN.CRNA.10348367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHP00689517OtherTRAVELERS RR MEDICARE
OH2940438Medicaid
OHPENDINGMedicaid
OH8243531Medicare PIN
OHPENDINGMedicare PIN