Healthcare Provider Details

I. General information

NPI: 1114957701
Provider Name (Legal Business Name): DAVID A. TRACEY PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 06/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

593 EDDY ST APC MAIN
PROVIDENCE RI
02903-4923
US

IV. Provider business mailing address

593 EDDY ST APC MAIN
PROVIDENCE RI
02903-4923
US

V. Phone/Fax

Practice location:
  • Phone: 401-444-5435
  • Fax: 401-444-5256
Mailing address:
  • Phone: 401-444-5435
  • Fax: 401-444-5256

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA00333
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: