Healthcare Provider Details

I. General information

NPI: 1275911083
Provider Name (Legal Business Name): TRACY C ECHUCK PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2015
Last Update Date: 02/03/2020
Certification Date: 02/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9035 KELLY BRIDGE RD
DAWSONVILLE GA
30534-4955
US

IV. Provider business mailing address

9035 KELLY BRIDGE RD
DAWSONVILLE GA
30534-4955
US

V. Phone/Fax

Practice location:
  • Phone: 770-480-1311
  • Fax:
Mailing address:
  • Phone: 770-480-1311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number153136
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: