Healthcare Provider Details

I. General information

NPI: 1134118573
Provider Name (Legal Business Name): TRACY HELEN HYDORN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2005
Last Update Date: 12/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 9TH ST
MARINA CA
93933-6039
US

IV. Provider business mailing address

PO BOX 2393
CARMEL CA
93921-2393
US

V. Phone/Fax

Practice location:
  • Phone: 831-884-1172
  • Fax: 831-884-1033
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA 13055
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: