Provider Demographics
NPI:1003121609
Name:ENNIS, TRACY R (PA-C)
Entity Type:Individual
Prefix:MS
First Name:TRACY
Middle Name:R
Last Name:ENNIS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2235 VENETIAN COURT
Mailing Address - Street 2:SUITE 1
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34109-8728
Mailing Address - Country:US
Mailing Address - Phone:239-596-9337
Mailing Address - Fax:239-596-9466
Practice Address - Street 1:2235 VENETIAN COURT
Practice Address - Street 2:SUITE 1
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34109-8728
Practice Address - Country:US
Practice Address - Phone:239-596-9337
Practice Address - Fax:239-596-9466
Is Sole Proprietor?:No
Enumeration Date:2010-08-09
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA 06798363A00000X
FLPA9108883363A00000X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLWYB4UOtherBCBS
FL017347700Medicaid
FLWYB4UOtherBCBS