Healthcare Provider Details

I. General information

NPI: 1003343138
Provider Name (Legal Business Name): TRACY JACINDA BRANCH PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2017
Last Update Date: 05/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8501 PLUM CREEK DR
GAITHERSBURG MD
20882-4438
US

IV. Provider business mailing address

5600 FISHERS LN # 16N164C
ROCKVILLE MD
20852-1750
US

V. Phone/Fax

Practice location:
  • Phone: 240-246-7510
  • Fax:
Mailing address:
  • Phone: 301-443-0494
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number007573
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: