Provider Demographics
NPI:1902851876
Name:PETRAC-HALATSIS, TAMARA PIROSKA (MD)
Entity Type:Individual
Prefix:DR
First Name:TAMARA
Middle Name:PIROSKA
Last Name:PETRAC-HALATSIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:TAMARA
Other - Middle Name:PIROSKA
Other - Last Name:PETRAC
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:5200 FAIRVIEW BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MN
Mailing Address - Zip Code:55092
Mailing Address - Country:US
Mailing Address - Phone:651-982-7670
Mailing Address - Fax:651-982-7675
Practice Address - Street 1:5200 FAIRVIEW BOULEVARD
Practice Address - Street 2:OB/GYN DEPARTMENT
Practice Address - City:WYOMING
Practice Address - State:MN
Practice Address - Zip Code:55092
Practice Address - Country:US
Practice Address - Phone:651-982-7670
Practice Address - Fax:651-982-7675
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2011-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME94155207V00000X
MN53965207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL274695600Medicaid
FL274695600Medicaid