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General NPI Number Information
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NPI Number | 1669563136
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Entity Type | Individual
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Provider Name | TRACY PETERSON R.P.A.C.
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Gender | Female
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Dates
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Enumeration Date | 09/27/2006
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Last Update Date | 10/02/2018
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Provider Practice Location Address
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Address Line | 1770 MOTOR PKWY
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City | ISLANDIA
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State | NY
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Zip | 11749-5260
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Country | US
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Telephone | 631-434-1770
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Fax | 631-434-1254
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Provider Business Mailing Address
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Address Line | 3001 EXPRESSWAY DR N
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City | ISLANDIA
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State | NY
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Zip | 11749-5301
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Country | US
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Telephone | 631-434-1770
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Fax | 631-434-1254
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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 | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 008224
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License Number State | NY
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