Provider Demographics
NPI:1033181193
Name:BLACK, TRACY REYMORE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:REYMORE
Last Name:BLACK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:8208 DEVON COURT
Mailing Address - Street 2:SUITE B
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29572
Mailing Address - Country:US
Mailing Address - Phone:704-364-6110
Mailing Address - Fax:704-364-4245
Practice Address - Street 1:8208 DEVON COURT
Practice Address - Street 2:SUITE B
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29572
Practice Address - Country:US
Practice Address - Phone:704-364-6110
Practice Address - Fax:704-364-4245
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2018-12-21
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NC101218363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant