Provider Demographics
NPI:1376623363
Name:ERVIN, TRACY (PT)
Entity type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:
Last Name:ERVIN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:754 N COLLEGE RD
Mailing Address - Street 2:STE D
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-5822
Mailing Address - Country:US
Mailing Address - Phone:208-734-5313
Mailing Address - Fax:208-736-1582
Practice Address - Street 1:754 N COLLEGE RD
Practice Address - Street 2:SUITE D
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-5822
Practice Address - Country:US
Practice Address - Phone:208-734-5313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2013-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDRPT1549225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805809600Medicaid
ID1651540Medicare PIN