Provider Demographics
NPI:1871777193
Name:SHAHAN, TRACI (WHNP-BC)
Entity type:Individual
Prefix:DR
First Name:TRACI
Middle Name:
Last Name:SHAHAN
Suffix:
Gender:F
Credentials:WHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 S AIRPORT RD BLDG A
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80503-6424
Mailing Address - Country:US
Mailing Address - Phone:720-378-6900
Mailing Address - Fax:877-241-8199
Practice Address - Street 1:600 S AIRPORT RD BLDG A
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80503-6424
Practice Address - Country:US
Practice Address - Phone:720-378-6900
Practice Address - Fax:877-241-8199
Is Sole Proprietor?:No
Enumeration Date:2007-12-21
Last Update Date:2017-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3082363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO112531OtherNURSING LICENSE