Provider Demographics
NPI:1538243837
Name:PROSEN, TRACY L (MD)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:L
Last Name:PROSEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55415-1623
Mailing Address - Country:US
Mailing Address - Phone:612-873-3000
Mailing Address - Fax:
Practice Address - Street 1:715 S 8TH ST
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-1210
Practice Address - Country:US
Practice Address - Phone:612-878-6963
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2022-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN40331207SG0201X, 207V00000X, 207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
No207SG0201XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Genetics (M.D.)
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNHP29213OtherHEALTH PARTNERS
MN07-00036OtherMEDICA PRIMARY
MN122548OtherUCARE
MT0081651Medicaid
MN1016399OtherPREFERRED ONE
MN2156402OtherARAZ
MN912320200Medicaid
MN07-04004OtherMEDICA CHOICE
MN549R6PROtherBLUE CROSS BLUE SHIELD
MT0081651Medicaid
160002385Medicare ID - Type Unspecified