Provider Demographics
NPI:1750612271
Name:OSWALD, TRACY LYNN
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:LYNN
Last Name:OSWALD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 6TH ST
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:MO
Mailing Address - Zip Code:64446-9222
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:405 E MAIN ST
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:MO
Practice Address - Zip Code:64446-8155
Practice Address - Country:US
Practice Address - Phone:660-686-2211
Practice Address - Fax:660-686-2618
Is Sole Proprietor?:No
Enumeration Date:2010-01-22
Last Update Date:2010-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000168641225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant