Basic Information
| Provider Information | |||||||||
| NPI: | 1093962722 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PEVETO | ||||||||
| FirstName: | TRACY | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | R.N., MSN, FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 650859 | ||||||||
| Address2: | DEPT 710 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752655302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4097476240 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2014 10TH ST | ||||||||
| Address2: | |||||||||
| City: | ORANGE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 776303431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4092661888 | ||||||||
| FaxNumber: | 4098833147 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2008 | ||||||||
| LastUpdateDate: | 08/02/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 637014 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | AP116915 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.