Healthcare Provider Details

I. General information

NPI: 1134519465
Provider Name (Legal Business Name): TRACI WALTERS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2015
Last Update Date: 05/30/2025
Certification Date: 05/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17495 LA GRANGE RD
TINLEY PARK IL
60487-7581
US

IV. Provider business mailing address

POB 7132960
CHICAGO IL
60677-0001
US

V. Phone/Fax

Practice location:
  • Phone: 708-226-7173
  • Fax: 708-226-7000
Mailing address:
  • Phone: 630-469-9200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085.005340
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: