Healthcare Provider Details

I. General information

NPI: 1972257558
Provider Name (Legal Business Name): TRACY LE DZIACKY PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/11/2022
Last Update Date: 09/11/2025
Certification Date: 11/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4701 NORMAL BLVD
LINCOLN NE
68506-5563
US

IV. Provider business mailing address

4701 NORMAL BLVD
LINCOLN NE
68506-5563
US

V. Phone/Fax

Practice location:
  • Phone: 402-488-5050
  • Fax:
Mailing address:
  • Phone: 402-488-5050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9115362
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: