Provider Demographics
NPI:1033314794
Name:EXLEY, TRACY RENEE (MD)
Entity Type:Individual
Prefix:DR
First Name:TRACY
Middle Name:RENEE
Last Name:EXLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:RENEE
Other - Last Name:POWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1132 SW 13TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-1703
Mailing Address - Country:US
Mailing Address - Phone:503-535-3827
Mailing Address - Fax:
Practice Address - Street 1:840 GUADALUPE PKWY
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95110
Practice Address - Country:US
Practice Address - Phone:408-299-4841
Practice Address - Fax:408-299-2511
Is Sole Proprietor?:No
Enumeration Date:2007-06-20
Last Update Date:2018-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD173883208000000X, 207R00000X
CAA108233207R00000X, 208000000X, 207RA0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0000XAllopathic & Osteopathic PhysiciansInternal MedicineAdolescent Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR181599Medicaid