Provider Demographics
NPI:1003343138
Name:BRANCH, TRACY JACINDA (PA)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:JACINDA
Last Name:BRANCH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5600 FISHERS LN # 16N164C
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-1750
Mailing Address - Country:US
Mailing Address - Phone:301-443-0494
Mailing Address - Fax:
Practice Address - Street 1:8501 PLUM CREEK DR
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20882-4438
Practice Address - Country:US
Practice Address - Phone:240-246-7510
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-19
Last Update Date:2017-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007573363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical