Healthcare Provider Details

I. General information

NPI: 1447653456
Provider Name (Legal Business Name): TRACY WICKERSHAM-FREY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2014
Last Update Date: 12/27/2023
Certification Date: 12/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 S BURMA AVE
GILLETTE WY
82716-3426
US

IV. Provider business mailing address

1121 WASHINGTON BLVD
NEWCASTLE WY
82701-2968
US

V. Phone/Fax

Practice location:
  • Phone: 307-688-1000
  • Fax:
Mailing address:
  • Phone: 307-746-3582
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: