Healthcare Provider Details

I. General information

NPI: 1902042104
Provider Name (Legal Business Name): TRACY HUGH TIPPETS RPA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/18/2008
Last Update Date: 12/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 OAK LN
KAYSVILLE UT
84037-1635
US

IV. Provider business mailing address

240 OAK LN
KAYSVILLE UT
84037-1635
US

V. Phone/Fax

Practice location:
  • Phone: 801-543-1301
  • Fax:
Mailing address:
  • Phone: 801-543-1301
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2471C3402X
TaxonomyRadiography Radiologic Technologist
License Number119162-5401
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code243U00000X
TaxonomyRadiology Practitioner Assistant
License Number09 UT 1-14
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: