Provider Demographics
NPI:1023007929
Name:TRACY, MARJORIA MARIE (CNM)
Entity Type:Individual
Prefix:
First Name:MARJORIA
Middle Name:MARIE
Last Name:TRACY
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:143 NORTH ST
Mailing Address - Street 2:SUITE #4
Mailing Address - City:AUBURN
Mailing Address - State:NY
Mailing Address - Zip Code:13021-1852
Mailing Address - Country:US
Mailing Address - Phone:315-252-5028
Mailing Address - Fax:315-252-1587
Practice Address - Street 1:143 NORTH ST
Practice Address - Street 2:SUITE #4
Practice Address - City:AUBURN
Practice Address - State:NY
Practice Address - Zip Code:13021-1852
Practice Address - Country:US
Practice Address - Phone:315-252-5028
Practice Address - Fax:315-252-5028
Is Sole Proprietor?:No
Enumeration Date:2005-10-14
Last Update Date:2011-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0280F000858367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01979193Medicaid
NYRB9246Medicare PIN