MEDICARE: TRACY L KNAAK PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AS0400X	Surgical Physician Assistant	0110001540	VA
2	363A00000X	Physician Assistant	0110001540	VA

General Provider Information

NPI Number	:	1669418174
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRACY L KNAAK PA-C

Provider Business Mailing Address
First Line	:	5818 HARBOUR VIEW BLVD STE 240
Second Line	:
City	:	SUFFOLK
State	:	VA
Zip	:	23435-3315
Country	:	US
Telephone Number	:	757-397-2383
Fax Number	:	757-673-0236

Provider Business Practice Location Address
First Line	:	5818 HARBOUR VIEW BLVD STE 240
Second Line	:
City	:	SUFFOLK
State	:	VA
Zip	:	23435-3315
Country	:	US
Telephone Number	:	757-397-2383
Fax Number	:	757-673-0236

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/22/2006
Last Update Date	:	01/05/2021

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