Provider Demographics
NPI:1548343205
Name:WILSON, TRACY ALLISON (LMP)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:ALLISON
Last Name:WILSON
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10644 FIRE POPPY CIR
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89521-6277
Mailing Address - Country:US
Mailing Address - Phone:775-292-0610
Mailing Address - Fax:775-292-0610
Practice Address - Street 1:1000 BIBLE WAY STE 73
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89502-2134
Practice Address - Country:US
Practice Address - Phone:775-292-0610
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2013-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00020990174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0197543OtherWA LABOR & INDUSTRIES