Healthcare Provider Details

I. General information

NPI: 1033314794
Provider Name (Legal Business Name): TRACY RENEE EXLEY M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TRACY RENEE POWELL

II. Dates (important events)

Enumeration Date: 06/20/2007
Last Update Date: 07/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

840 GUADALUPE PKWY
SAN JOSE CA
95110
US

IV. Provider business mailing address

1132 SW 13TH AVE
PORTLAND OR
97205-1703
US

V. Phone/Fax

Practice location:
  • Phone: 408-299-4841
  • Fax: 408-299-2511
Mailing address:
  • Phone: 503-535-3827
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD173883
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD173883
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA108233
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA108233
License Number StateCA
# 5
Primary TaxonomyY
Taxonomy Code207RA0000X
TaxonomyAdolescent Medicine (Internal Medicine) Physician
License NumberA108233
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: