Provider Demographics
NPI:1972507929
Name:TRAGESER, TIMOTHY
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:TRAGESER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 E 2ND ST FL 2
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16507-1579
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:120 E 2ND ST FL 2
Practice Address - Street 2:2ND FLOOR
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16507-1579
Practice Address - Country:US
Practice Address - Phone:814-456-8980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-08
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD044482L207RI0011X, 207RI0011X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001252906Medicaid
NY01497543Medicaid
NYCC7289Medicare ID - Type Unspecified
NY01497543Medicaid
OH0999693Medicaid
PA675541Medicare ID - Type Unspecified