Healthcare Provider Details

I. General information

NPI: 1225297724
Provider Name (Legal Business Name): TRACY HUNTINGTON CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2008
Last Update Date: 05/07/2025
Certification Date: 05/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 ORCHARD DR
SISSETON SD
57262-2312
US

IV. Provider business mailing address

PO BOX 6001
FARGO ND
58108-6001
US

V. Phone/Fax

Practice location:
  • Phone: 605-698-4665
  • Fax: 605-698-6401
Mailing address:
  • Phone: 701-364-8000
  • Fax: 701-364-8078

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberCR000703
License Number StateSD
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR30191
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: