Healthcare Provider Details

I. General information

NPI: 1295923985
Provider Name (Legal Business Name): ANDY JOHN TRACY CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2007
Last Update Date: 10/15/2024
Certification Date: 10/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2650 RIDGE AVE
EVANSTON IL
60201-1700
US

IV. Provider business mailing address

2650 RIDGE AVE
EVANSTON IL
60201-1700
US

V. Phone/Fax

Practice location:
  • Phone: 847-570-2760
  • Fax: 847-570-2921
Mailing address:
  • Phone: 847-570-2040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209.006942
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberRN 041-330738
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: