Provider Demographics
NPI:1003828351
Name:PATEL, TRACIE L (PA)
Entity Type:Individual
Prefix:
First Name:TRACIE
Middle Name:L
Last Name:PATEL
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:PO BOX 1289
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33601-1289
Mailing Address - Country:US
Mailing Address - Phone:813-844-8927
Mailing Address - Fax:
Practice Address - Street 1:10740 PALM RIVER RD STE 360
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33619-4578
Practice Address - Country:US
Practice Address - Phone:813-844-7585
Practice Address - Fax:813-844-5877
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9102082363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL291352600Medicaid
FLY00S9OtherBLUE CROSS BLUE SHIELD
FL291352600Medicaid
FLE8080ZMedicare PIN