Provider Demographics
NPI:1932159183
Name:PANTZKE, TRACI LYNN (CRNA)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:LYNN
Last Name:PANTZKE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:TRACI
Other - Middle Name:LYNN
Other - Last Name:OLSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:2301 25TH ST S
Mailing Address - Street 2:STE K
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-6104
Mailing Address - Country:US
Mailing Address - Phone:701-234-1728
Mailing Address - Fax:701-234-1628
Practice Address - Street 1:2301 25TH ST S
Practice Address - Street 2:STE K
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-6104
Practice Address - Country:US
Practice Address - Phone:701-234-1728
Practice Address - Fax:701-234-1628
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR22825367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND020823OtherND BLUE SHIELD
MN131R8PAOtherMN BLUE SHIELD
ND10221Medicaid
ND10221Medicaid