Basic Information
| Provider Information | |||||||||
| NPI: | 1528054103 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHANNSEN | ||||||||
| FirstName: | TRACY | ||||||||
| MiddleName: | A. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1101 MADISON ST | ||||||||
| Address2: | #1150 | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981041306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2063863400 | ||||||||
| FaxNumber: | 2063863411 | ||||||||
| Practice Location | |||||||||
| Address1: | 1101 MADISON ST | ||||||||
| Address2: | #1150 | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981041306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2063863400 | ||||||||
| FaxNumber: | 2063863411 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2005 | ||||||||
| LastUpdateDate: | 05/23/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | MD00021154 | WA | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 1012496 | 05 | WA | MEDICAID |