Healthcare Provider Details

I. General information

NPI: 1356962211
Provider Name (Legal Business Name): TRACEY LY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2020
Last Update Date: 11/18/2025
Certification Date: 11/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 GRESHAM DR STE 700
NORFOLK VA
23507-1904
US

IV. Provider business mailing address

6275 E VIRGINIA BEACH BLVD STE 300
NORFOLK VA
23502-2851
US

V. Phone/Fax

Practice location:
  • Phone: 757-388-1700
  • Fax: 423-826-1290
Mailing address:
  • Phone: 757-466-0089
  • Fax: 757-466-8017

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number58446
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110009247
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: