Healthcare Provider Details

I. General information

NPI: 1538205851
Provider Name (Legal Business Name): TRACY LYNNE CUMBERLAND PA-C, PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: TRACY LYNNE SMITH PA-C

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 12/27/2022
Certification Date: 12/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5750 W THUNDERBIRD RD STE B200
GLENDALE AZ
85306-4664
US

IV. Provider business mailing address

14044 W CAMELBACK RD STE 118J
LITCHFIELD PARK AZ
85340-9428
US

V. Phone/Fax

Practice location:
  • Phone: 602-375-1700
  • Fax: 602-978-1225
Mailing address:
  • Phone: 623-547-2600
  • Fax: 623-547-1899

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC01254
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number7357
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: