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Individual
TRACEY WILSON
Active
Individual
TRACEY WILSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
CRNP
Taxonomy
Speciality
Code
Description
License number
State
363LA2100X
Acute Care Nurse Practitioner
R115362
MD
363LC0200X
Critical Care Medicine Nurse Practitioner
Primary
R115362
MD
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
419033500
—
MD
01
—
960542-01 & 02
BLUE CROSS/BLUE SHIELD
MD
01
—
S062-0375
BLUE SHIELD REGIONAL
MD
Enumeration date
04/16/2008
Last updated
08/12/2015
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