Healthcare Provider Details

I. General information

NPI: 1508912197
Provider Name (Legal Business Name): TRACY CASAULT D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2007
Last Update Date: 11/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 UCB
BOULDER CO
80309-0119
US

IV. Provider business mailing address

119 UCB
BOULDER CO
80309-0119
US

V. Phone/Fax

Practice location:
  • Phone: 303-492-5101
  • Fax:
Mailing address:
  • Phone: 303-492-5101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number45638
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: