Healthcare Provider Details

I. General information

NPI: 1891836045
Provider Name (Legal Business Name): TRACI M. MORELAND MPA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2007
Last Update Date: 07/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1455 HARRISON AVE NW SUITE 105
CANTON OH
44708-2621
US

IV. Provider business mailing address

1455 HARRISON AVE NW SUITE 105
CANTON OH
44708-2621
US

V. Phone/Fax

Practice location:
  • Phone: 330-453-9993
  • Fax: 330-453-9996
Mailing address:
  • Phone: 330-453-9993
  • Fax: 330-453-9996

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50-00-1745
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: