Provider Demographics
NPI:1699767020
Name:KUTSENKOW, TRACY CLAIRE (NP)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:CLAIRE
Last Name:KUTSENKOW
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4551 N COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93704-3808
Mailing Address - Country:US
Mailing Address - Phone:559-435-6477
Mailing Address - Fax:559-435-4220
Practice Address - Street 1:2511 LOGAN ST
Practice Address - Street 2:LOGAN STREET MEDICAL GROUP
Practice Address - City:SELMA
Practice Address - State:CA
Practice Address - Zip Code:93662-3012
Practice Address - Country:US
Practice Address - Phone:559-896-2624
Practice Address - Fax:559-896-3235
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA308978363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ-151-572Medicare ID - Type Unspecified
CAZZZ06998ZMedicare PIN
S61308Medicare UPIN