Provider Demographics
NPI:1952385304
Name:POWELL, TRACY ALAN (MD)
Entity Type:Individual
Prefix:MR
First Name:TRACY
Middle Name:ALAN
Last Name:POWELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2414 WALDEN WAY
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56301-9071
Mailing Address - Country:US
Mailing Address - Phone:320-253-7127
Mailing Address - Fax:
Practice Address - Street 1:303 CATLIN ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:MN
Practice Address - Zip Code:55313-1947
Practice Address - Country:US
Practice Address - Phone:763-684-7500
Practice Address - Fax:763-684-7515
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN32554207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIE41992Medicare UPIN