Provider Demographics
NPI:1689332041
Name:BANGHART, TRACY (NP)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:BANGHART
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1331 STATE ST STE 340
Mailing Address - Street 2:
Mailing Address - City:LA PORTE
Mailing Address - State:IN
Mailing Address - Zip Code:46350-3112
Mailing Address - Country:US
Mailing Address - Phone:219-324-0875
Mailing Address - Fax:219-324-0827
Practice Address - Street 1:1331 STATE ST STE 340
Practice Address - Street 2:
Practice Address - City:LA PORTE
Practice Address - State:IN
Practice Address - Zip Code:46350-3112
Practice Address - Country:US
Practice Address - Phone:219-324-0875
Practice Address - Fax:219-324-0827
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-02
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71011976A163WG0100X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WG0100XNursing Service ProvidersRegistered NurseGastroenterologyGroup - Single Specialty