Provider Demographics
NPI:1104478551
Name:LONG, TRACEY BATES (RN, APRN, PHD)
Entity type:Individual
Prefix:DR
First Name:TRACEY
Middle Name:BATES
Last Name:LONG
Suffix:
Gender:F
Credentials:RN, APRN, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10550 HABERSHAM CT
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89183-4551
Mailing Address - Country:US
Mailing Address - Phone:702-301-9560
Mailing Address - Fax:
Practice Address - Street 1:7501 FANNIN ST STE 705
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77054-1958
Practice Address - Country:US
Practice Address - Phone:713-589-5283
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-15
Last Update Date:2019-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV822517363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care