Provider Demographics
NPI:1679543383
Name:COUSINS, TRACY L (MD)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:L
Last Name:COUSINS
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 1:2800 WESTHILL DR
Mailing Address - Street 2:SUITE 208
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-3771
Mailing Address - Country:US
Mailing Address - Phone:715-847-0075
Mailing Address - Fax:
Practice Address - Street 1:333 PINE RIDGE BLVD
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401-4120
Practice Address - Country:US
Practice Address - Phone:715-847-2130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI35452207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32045200Medicaid
F82590Medicare UPIN
WI001439153Medicare ID - Type Unspecified