Provider Demographics
NPI:1548311731
Name:MAXWELL, TRACY A (CRNA)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:A
Last Name:MAXWELL
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 6002
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61803-6002
Mailing Address - Country:US
Mailing Address - Phone:217-326-8300
Mailing Address - Fax:
Practice Address - Street 1:602 W. UNIVERSITY AVENUE
Practice Address - Street 2:FAMILY MEDICINE
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61801
Practice Address - Country:US
Practice Address - Phone:217-383-5162
Practice Address - Fax:217-383-7650
Is Sole Proprietor?:No
Enumeration Date:2007-01-15
Last Update Date:2012-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209001233367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL3270256Medicare PIN
IL6447860013Medicare NSC
P20573Medicare UPIN