Provider Demographics
NPI:1215289897
Name:RADOVAN, TRACEY F (PT)
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:F
Last Name:RADOVAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2266 DOC HOLIDAY DR
Mailing Address - Street 2:
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84060-7428
Mailing Address - Country:US
Mailing Address - Phone:602-617-3742
Mailing Address - Fax:
Practice Address - Street 1:2015 SIDEWINDER DR
Practice Address - Street 2:
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84060-7323
Practice Address - Country:US
Practice Address - Phone:435-645-9095
Practice Address - Fax:435-645-9092
Is Sole Proprietor?:No
Enumeration Date:2012-10-08
Last Update Date:2012-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8244561-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist