Provider Demographics
NPI:1669705331
Name:WATERS, TRACI (CRNA)
Entity type:Individual
Prefix:
First Name:TRACI
Middle Name:
Last Name:WATERS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 W ASH ST
Mailing Address - Street 2:
Mailing Address - City:DEMING
Mailing Address - State:NM
Mailing Address - Zip Code:88030-4000
Mailing Address - Country:US
Mailing Address - Phone:575-546-5855
Mailing Address - Fax:575-546-5855
Practice Address - Street 1:900 W ASH ST
Practice Address - Street 2:
Practice Address - City:DEMING
Practice Address - State:NM
Practice Address - Zip Code:88030-4000
Practice Address - Country:US
Practice Address - Phone:575-546-5855
Practice Address - Fax:575-543-6908
Is Sole Proprietor?:No
Enumeration Date:2009-09-14
Last Update Date:2010-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCRNA-01052367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM64180379Medicaid
NM64180379Medicaid