Healthcare Provider Details

I. General information

NPI: 1962603530
Provider Name (Legal Business Name): TRACY ANNE TAGGART M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DR. TRACY TAGGART WIESBERG

II. Dates (important events)

Enumeration Date: 05/30/2007
Last Update Date: 08/22/2025
Certification Date: 08/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18523 CORWIN RD STE A
APPLE VALLEY CA
92307-2300
US

IV. Provider business mailing address

1115 SE 164TH AVE DEPT 358
VANCOUVER WA
98683-8004
US

V. Phone/Fax

Practice location:
  • Phone: 909-712-2764
  • Fax:
Mailing address:
  • Phone: 360-729-1462
  • Fax: 360-729-3104

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD-48236
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD60957762
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberC175274
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License NumberMD-48236
License Number StateIA
# 5
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number27912
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: