Provider Demographics
NPI:1033921903
Name:GASTELUM, TRACY I (AGACNP-BC)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:I
Last Name:GASTELUM
Suffix:
Gender:F
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 N CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95351-4804
Mailing Address - Country:US
Mailing Address - Phone:209-606-7800
Mailing Address - Fax:
Practice Address - Street 1:1700 COFFEE RD
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-2803
Practice Address - Country:US
Practice Address - Phone:209-526-4500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-27
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95033701363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care