Healthcare Provider Details

I. General information

NPI: 1962418665
Provider Name (Legal Business Name): TRACY ASAMOAH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 04/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 W UNIVERSITY AVE STE. 103
GEORGETOWN TX
78628-7108
US

IV. Provider business mailing address

1500 W UNIVERSITY AVE STE. 103
GEORGETOWN TX
78628-7108
US

V. Phone/Fax

Practice location:
  • Phone: 512-868-1124
  • Fax:
Mailing address:
  • Phone: 512-868-1124
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number2004-0507
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: