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General NPI Number Information
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NPI Number | 1174055784
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Entity Type | Individual
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Provider Name | TRACEY H FAN D.O
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Gender | Female
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Dates
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Enumeration Date | 04/02/2017
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Last Update Date | 11/19/2025
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Provider Practice Location Address
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Address Line | 55 FRUIT ST # 721J
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City | BOSTON
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State | MA
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Zip | 02114-2696
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Country | US
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Telephone | 617-726-2000
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Fax |
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Provider Business Mailing Address
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Address Line | 20 ENGLEWOOD AVE APT 104
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City | BROOKLINE
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State | MA
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Zip | 02445-2072
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084N0400X
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Taxonomy Name | Neurology Physician
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License Number | DO-06915
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License Number State | IA
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Taxonomy #2
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Taxonomy Code | 2084N0400X
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Taxonomy Name | Neurology Physician
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License Number | OS024561C
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License Number State | PA
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Taxonomy #3
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Taxonomy Code | 2084N0400X
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Taxonomy Name | Neurology Physician
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License Number | 287765
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License Number State | MA
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