Basic Information
| Provider Information | |||||||||
| NPI: | 1962603530 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TAGGART | ||||||||
| FirstName: | TRACY | ||||||||
| MiddleName: | ANNE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WIESBERG | ||||||||
| OtherFirstName: | TRACY | ||||||||
| OtherMiddleName: | TAGGART | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1115 SE 164TH AVE DEPT 358 | ||||||||
| Address2: | |||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986838004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607291462 | ||||||||
| FaxNumber: | 3607293104 | ||||||||
| Practice Location | |||||||||
| Address1: | PEACEHEALTH UNITED GENERAL MEDICAL CENTER | ||||||||
| Address2: | 2000 HOSPITAL DRIVE | ||||||||
| City: | SEDRO WOOLLEY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98284 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3608567588 | ||||||||
| FaxNumber: | 3608567252 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2007 | ||||||||
| LastUpdateDate: | 09/22/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | MD-48236 | IA | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | MD60957762 | WA | N | Allopathic & Osteopathic Physicians | Surgery | 2086S0127X | MD-48236 | IA | N | Allopathic & Osteopathic Physicians | Surgery | Trauma Surgery | 208600000X | 27912 | OR | Y | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.