Healthcare Provider Details

I. General information

NPI: 1609109024
Provider Name (Legal Business Name): TRACY MARIE SMITH PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TRACY MARIE LAZUR PA-C

II. Dates (important events)

Enumeration Date: 09/16/2009
Last Update Date: 09/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4190 CITY AVE SUITE 528
PHILADELPHIA PA
19131-1626
US

IV. Provider business mailing address

260 CALLE CAMPESINO
SAN CLEMENTE CA
92672-4553
US

V. Phone/Fax

Practice location:
  • Phone: 866-453-8800
  • Fax: 844-734-7689
Mailing address:
  • Phone: 949-366-1053
  • Fax: 949-544-7880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberMA054091
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA21436
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: