MEDICARE: TRACY L OELLER PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA01476	TX

General Provider Information

NPI Number	:	1053490425
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRACY L OELLER PA

Provider Business Mailing Address
First Line	:	6100 LAKE WORTH BLVD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76135-3703
Country	:	US
Telephone Number	:	817-237-3321
Fax Number	:	817-237-7970

Provider Business Practice Location Address
First Line	:	6100 LAKE WORTH BLVD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76135-3703
Country	:	US
Telephone Number	:	817-237-3321
Fax Number	:	817-237-7970

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/04/2006
Last Update Date	:	02/20/2015

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Directions to “ TRACY L OELLER PA” Practice Location

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