Provider Demographics
NPI:1316108301
Name:FOX, TRACEY L (MSN, FNP)
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:L
Last Name:FOX
Suffix:
Gender:F
Credentials:MSN, FNP
Other - Prefix:
Other - First Name:TRACEY
Other - Middle Name:F
Other - Last Name:DURST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1400 SW 5TH AVE STE 500
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97201-5537
Mailing Address - Country:US
Mailing Address - Phone:666-176-8558
Mailing Address - Fax:503-346-8015
Practice Address - Street 1:3303 S BOND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-4501
Practice Address - Country:US
Practice Address - Phone:503-494-5058
Practice Address - Fax:503-494-5065
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-23
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEAP081908363L00000X
MER052968363LF0000X
OR201504213NP-PP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME00937502Medicare PIN