MEDICARE: TRACY PHAN NP

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	363LF0000X	Family Nurse Practitioner	NP95013765	CA

General Provider Information

NPI Number	:	1972137446
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRACY PHAN NP

Provider Business Mailing Address
First Line	:	1569 LEXANN AVE
Second Line	:	STE 114
City	:	SAN JOSE
State	:	CA
Zip	:	95121-1794
Country	:	US
Telephone Number	:	408-680-1940
Fax Number	:

Provider Business Practice Location Address
First Line	:	969 STORY RD UNIT 6060A
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95122-4601
Country	:	US
Telephone Number	:	408-223-8818
Fax Number	:

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

Provider Enumeration Date	:	02/24/2020
Last Update Date	:	10/29/2020

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