Healthcare Provider Details

I. General information

NPI: 1871721936
Provider Name (Legal Business Name): WILLIAM TRACY MOCK RN, MSN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2009
Last Update Date: 06/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5201 RAYMOND ST ORLANDO VA MEDICAL CENTER
ORLANDO FL
32803
US

IV. Provider business mailing address

1237 KILLARNEY DR
ORMOND BEACH FL
32174-2828
US

V. Phone/Fax

Practice location:
  • Phone: 407-599-1543
  • Fax:
Mailing address:
  • Phone: 386-492-6024
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License NumberRN1472152
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: