Provider Demographics
NPI:1740494806
Name:HULTGREN, TRICIA L (MD)
Entity type:Individual
Prefix:
First Name:TRICIA
Middle Name:L
Last Name:HULTGREN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:909 N 96 ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68114-2508
Mailing Address - Country:US
Mailing Address - Phone:402-330-4555
Mailing Address - Fax:402-330-4626
Practice Address - Street 1:909 N 96 ST
Practice Address - Street 2:SUITE 201
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-2508
Practice Address - Country:US
Practice Address - Phone:402-330-4555
Practice Address - Fax:402-330-4626
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2012-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE25707207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE100255555000Medicaid
099992004Medicare PIN