Provider Demographics
NPI:1841303054
Name:ANDERSON, TRACEY (FNP)
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25150 HANCOCK AVE STE 210
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562-5989
Mailing Address - Country:US
Mailing Address - Phone:951-587-3739
Mailing Address - Fax:951-698-5213
Practice Address - Street 1:25150 HANCOCK AVE STE 210
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562-5989
Practice Address - Country:US
Practice Address - Phone:951-587-3739
Practice Address - Fax:951-698-5213
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95012750363LF0000X, 364SN0800X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No364SN0800XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistNeuroscience
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO25073567Medicaid
WYW23850Medicare PIN
CO25073567Medicaid
CO364286YLB8Medicare PIN