Healthcare Provider Details

I. General information

NPI: 1629288493
Provider Name (Legal Business Name): TRACY TIMMONS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 05/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 NE 87TH AVE SUITE 301
VANCOUVER WA
98664-1989
US

IV. Provider business mailing address

1115 SE 164TH AVE DEPT 358
VANCOUVER WA
98683-9324
US

V. Phone/Fax

Practice location:
  • Phone: 360-514-1854
  • Fax: 360-514-6063
Mailing address:
  • Phone: 360-729-1253
  • Fax: 360-575-3678

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number0101240754
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License NumberD71167
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License NumberD71167
License Number StateMD
# 4
Primary TaxonomyY
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License NumberMD60449813
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: