MEDICARE: TRACY LYNN LEONARD 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	363AM0700X	Medical Physician Assistant	0110002438	VA
2	363A00000X	Physician Assistant	0110002438	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0110002438	OTHER	VA	STATE LICENSE
2	541870680	OTHER	VA	ORGANIZATOIN TAX ID
3	541398620	OTHER	VA	ORGANIZATION TAX ID

General Provider Information

NPI Number	:	1801930169
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRACY LYNN LEONARD PA-C

Provider Business Mailing Address
First Line	:	1300 SENTARA PARK # 3
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23464-5884
Country	:	US
Telephone Number	:	757-252-3050
Fax Number	:

Provider Business Practice Location Address
First Line	:	1300 SENTARA PARK # 3
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23464-5884
Country	:	US
Telephone Number	:	757-252-3050
Fax Number	:

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

Provider Enumeration Date	:	02/19/2007
Last Update Date	:	04/17/2024

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