MEDICARE: TRACY M. CREEL PA-C

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	363AM0700X	Medical Physician Assistant	PA064	MS
2	363AM0700X	Medical Physician Assistant	PA9103034	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	Y0139	OTHER	FL	BLUECROSS/BLUESHIELD

General Provider Information

NPI Number	:	1871575324
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRACY M. CREEL PA-C

Provider Business Mailing Address
First Line	:	411 WEBSTER ST
Second Line	:
City	:	WILDWOOD
State	:	FL
Zip	:	34785-4036
Country	:	US
Telephone Number	:	352-748-6689
Fax Number	:	352-748-6381

Provider Business Practice Location Address
First Line	:	411 WEBSTER ST
Second Line	:
City	:	WILDWOOD
State	:	FL
Zip	:	34785-4036
Country	:	US
Telephone Number	:	352-748-6689
Fax Number	:	352-748-6381

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

Provider Enumeration Date	:	11/18/2005
Last Update Date	:	03/21/2011

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