Healthcare Provider Details

I. General information

NPI: 1013136415
Provider Name (Legal Business Name): JACQUELINE TRACEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 09/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 MEDICAL PARK DR SUITE 430
CONCORD NC
28025-2982
US

IV. Provider business mailing address

200 MEDICAL PARK DRIVE
CONCORD NC
28025
US

V. Phone/Fax

Practice location:
  • Phone: 704-403-7070
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number2015-01537
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: