Healthcare Provider Details

I. General information

NPI: 1700229846
Provider Name (Legal Business Name): TRACY DRAKE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TRACY HANSEN

II. Dates (important events)

Enumeration Date: 04/08/2013
Last Update Date: 08/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 PLEASANT VALLEY RD
WEST BEND WI
53095-9274
US

IV. Provider business mailing address

3200 PLEASANT VALLEY RD
WEST BEND WI
53095-9274
US

V. Phone/Fax

Practice location:
  • Phone: 262-334-5533
  • Fax:
Mailing address:
  • Phone: 262-334-5533
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number62995-20
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number62995-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: