Healthcare Provider Details

I. General information

NPI: 1245726918
Provider Name (Legal Business Name): TRACY LYN HAGADORN CPM, LM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2018
Last Update Date: 07/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

182 STATE STREET
EAGLE ID
83616
US

IV. Provider business mailing address

806 EAGLE HILLS WAY
EAGLE ID
83616-5212
US

V. Phone/Fax

Practice location:
  • Phone: 208-631-8910
  • Fax:
Mailing address:
  • Phone: 208-631-8910
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License NumberMID-86
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: