Provider Demographics
NPI:1245663657
Name:DOZAK, TRACY LYNN (NP-C)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:LYNN
Last Name:DOZAK
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:LYNN
Other - Last Name:WEBER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:450 EASTVOLD AVE
Mailing Address - Street 2:
Mailing Address - City:ORTONVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:56278-1252
Mailing Address - Country:US
Mailing Address - Phone:320-839-6157
Mailing Address - Fax:320-839-3851
Practice Address - Street 1:450 EASTVOLD AVE
Practice Address - Street 2:
Practice Address - City:ORTONVILLE
Practice Address - State:MN
Practice Address - Zip Code:56278-1133
Practice Address - Country:US
Practice Address - Phone:320-839-6157
Practice Address - Fax:320-839-3851
Is Sole Proprietor?:No
Enumeration Date:2013-08-21
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3082363LF0000X
NDR32847363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1245663657Medicaid