Healthcare Provider Details

I. General information

NPI: 1710362538
Provider Name (Legal Business Name): TRACY MAST APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2015
Last Update Date: 04/30/2026
Certification Date: 04/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1908 N 14TH ST STE 104
PONCA CITY OK
74601-2049
US

IV. Provider business mailing address

3001 QUAIL SPRINGS PKWY FL 5
OKLAHOMA CITY OK
73134-2640
US

V. Phone/Fax

Practice location:
  • Phone: 580-765-0212
  • Fax: 580-763-0873
Mailing address:
  • Phone: 580-765-0212
  • Fax: 580-763-0873

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberR0090312
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: