Provider Demographics
NPI:1962591263
Name:AMMANN, TRACY L (OD)
Entity type:Individual
Prefix:DR
First Name:TRACY
Middle Name:L
Last Name:AMMANN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:704 E FREMONT AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:WY
Mailing Address - Zip Code:82501-4421
Mailing Address - Country:US
Mailing Address - Phone:307-856-9000
Mailing Address - Fax:307-856-9004
Practice Address - Street 1:704 E FREMONT AVE
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:WY
Practice Address - Zip Code:82501-4421
Practice Address - Country:US
Practice Address - Phone:307-856-9000
Practice Address - Fax:307-856-9004
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2010-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY261T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY120883700Medicaid
WY5622650001Medicare NSC
WYU71698Medicare UPIN