MEDICARE: TRACI PATTERSON P.T.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	2001018686	MO

General Provider Information

NPI Number	:	1861803900
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRACI PATTERSON P.T.

Provider Business Mailing Address
First Line	:	1802 SAINT FRANCIS ST
Second Line	:
City	:	KENNETT
State	:	MO
Zip	:	63857-1568
Country	:	US
Telephone Number	:	573-888-1044
Fax Number	:

Provider Business Practice Location Address
First Line	:	1802 SAINT FRANCIS ST
Second Line	:
City	:	KENNETT
State	:	MO
Zip	:	63857-1568
Country	:	US
Telephone Number	:	573-888-1044
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/12/2014
Last Update Date	:	05/12/2014

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