Healthcare Provider Details

I. General information

NPI: 1487783080
Provider Name (Legal Business Name): TRACI CARDINAL PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2007
Last Update Date: 08/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 WOODMAN DR
DAYTON OH
45432-1400
US

IV. Provider business mailing address

877C STONE CROSSING LN
SPRINGFIELD OH
45503-5062
US

V. Phone/Fax

Practice location:
  • Phone: 937-252-2000
  • Fax:
Mailing address:
  • Phone: 678-471-1252
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number50.003064
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: