Provider Demographics
NPI:1831625805
Name:NOGLE, TRACY (DO)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:NOGLE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7243 DELLA DR STE 1
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32819-5104
Mailing Address - Country:US
Mailing Address - Phone:321-843-5851
Mailing Address - Fax:
Practice Address - Street 1:7243 DELLA DR STE 1
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32819-5104
Practice Address - Country:US
Practice Address - Phone:321-843-5851
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-11
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101025655207Q00000X
FLOS15631207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL119732000Medicaid