Provider Demographics
NPI:1134226293
Name:LARRISON, TRACEY D (DO)
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:D
Last Name:LARRISON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4821 SW 9TH ST
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50315-3802
Mailing Address - Country:US
Mailing Address - Phone:515-262-8471
Mailing Address - Fax:515-266-9783
Practice Address - Street 1:4821 SW 9TH ST
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50315-3802
Practice Address - Country:US
Practice Address - Phone:515-262-8471
Practice Address - Fax:515-266-9783
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA2955207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1155671Medicaid
IAI20004Medicare PIN
IA1155671Medicaid