Provider Demographics
NPI:1992024400
Name:KOLUND, TRACEY E (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:TRACEY
Middle Name:E
Last Name:KOLUND
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:TRACEY
Other - Middle Name:E
Other - Last Name:HYDA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 10190
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23450-0190
Mailing Address - Country:US
Mailing Address - Phone:800-477-5240
Mailing Address - Fax:757-463-6572
Practice Address - Street 1:8303 DODGE ST
Practice Address - Street 2:SUITE 300
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-4108
Practice Address - Country:US
Practice Address - Phone:403-354-5250
Practice Address - Fax:402-354-3437
Is Sole Proprietor?:No
Enumeration Date:2010-05-24
Last Update Date:2013-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA002099363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025044500Medicaid
NE10025044500Medicaid