Provider Demographics
NPI:1194997858
Name:HOGAN, TRACY L (RN)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:L
Last Name:HOGAN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9212 STONE SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:OMRO
Mailing Address - State:WI
Mailing Address - Zip Code:54963-9766
Mailing Address - Country:US
Mailing Address - Phone:920-685-2193
Mailing Address - Fax:
Practice Address - Street 1:9212 STONE SCHOOL RD
Practice Address - Street 2:
Practice Address - City:OMRO
Practice Address - State:WI
Practice Address - Zip Code:54963-9766
Practice Address - Country:US
Practice Address - Phone:920-685-2193
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-01
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39889400Medicaid