Healthcare Provider Details

I. General information

NPI: 1285104216
Provider Name (Legal Business Name): TRACY TARTAGLIONE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TRACY MICHNIK

II. Dates (important events)

Enumeration Date: 12/03/2018
Last Update Date: 10/22/2020
Certification Date: 10/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13350 FRANKLIN FARM RD STE 220
HERNDON VA
20171-4095
US

IV. Provider business mailing address

PO BOX 75868
BALTIMORE MD
21275-5868
US

V. Phone/Fax

Practice location:
  • Phone: 703-810-5204
  • Fax: 703-810-5411
Mailing address:
  • Phone: 703-383-6469
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110001401
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: