Healthcare Provider Details

I. General information

NPI: 1568385243
Provider Name (Legal Business Name): TRACEY C MATHIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2026
Last Update Date: 07/31/2026
Certification Date: 07/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4530 30TH AVE NW UNIT 103
MANDAN ND
58554-1322
US

IV. Provider business mailing address

4530 30TH AVE NW UNIT 103
MANDAN ND
58554-1322
US

V. Phone/Fax

Practice location:
  • Phone: 701-518-6407
  • Fax:
Mailing address:
  • Phone: 701-518-6407
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: