Provider Demographics
NPI:1043219520
Name:MAYNOR, TRACEY GREGORY (PAC)
Entity Type:Individual
Prefix:MRS
First Name:TRACEY
Middle Name:GREGORY
Last Name:MAYNOR
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:TRACEY
Other - Middle Name:DANN
Other - Last Name:GREGORY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:4003 KRESGE WAY
Mailing Address - Street 2:#221
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-4652
Mailing Address - Country:US
Mailing Address - Phone:502-897-7107
Mailing Address - Fax:502-897-7613
Practice Address - Street 1:4003 KRESGE WAY
Practice Address - Street 2:#221
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4652
Practice Address - Country:US
Practice Address - Phone:502-897-7107
Practice Address - Fax:502-897-7613
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA 549363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY9500175600Medicaid
1262110Medicare ID - Type Unspecified
KY9500175600Medicaid