Healthcare Provider Details

I. General information

NPI: 1902003122
Provider Name (Legal Business Name): TRACIE CAROL TARTER P.T.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 NORFLEET DR
SOMERSET KY
42501-1952
US

IV. Provider business mailing address

512 HIDDEN LOOP DR
SOMERSET KY
42503-9610
US

V. Phone/Fax

Practice location:
  • Phone: 606-678-5104
  • Fax: 606-677-1925
Mailing address:
  • Phone: 606-678-8069
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberAO1119
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: