Healthcare Provider Details

I. General information

NPI: 1801241161
Provider Name (Legal Business Name): TRACY FABIAN DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2016
Last Update Date: 06/09/2020
Certification Date: 06/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 N MAIN ST
WARSAW NY
14569-1025
US

IV. Provider business mailing address

401 MAIN ST
ARCADE NY
14009-1113
US

V. Phone/Fax

Practice location:
  • Phone: 585-786-1541
  • Fax: 585-492-4681
Mailing address:
  • Phone: 585-492-5088
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number298982
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: