Provider Demographics
NPI:1154594109
Name:HALL, TRACY GOETZ (MD)
Entity type:Individual
Prefix:DR
First Name:TRACY
Middle Name:GOETZ
Last Name:HALL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:JEAN
Other - Last Name:GOETZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:17705 HUTCHINS DRIVE, SUITE 101
Mailing Address - Street 2:SOUTH LAKE PEDIATRICS
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55345
Mailing Address - Country:US
Mailing Address - Phone:952-401-8300
Mailing Address - Fax:952-401-8373
Practice Address - Street 1:17705 HUTCHINS DR
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55345-4145
Practice Address - Country:US
Practice Address - Phone:952-401-8300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-10
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN54821208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics