Healthcare Provider Details

I. General information

NPI: 1366947533
Provider Name (Legal Business Name): TRACY ANNE MIX PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2018
Last Update Date: 12/20/2022
Certification Date: 12/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33300 CLEVELAND CLINIC BLVD
AVON OH
44011-1172
US

IV. Provider business mailing address

27664 WESTCHESTER PKWY APT A
WESTLAKE OH
44145-1216
US

V. Phone/Fax

Practice location:
  • Phone: 440-371-8395
  • Fax:
Mailing address:
  • Phone: 937-681-0383
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601008591
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number025684
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.005845RX
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: