Provider Demographics
NPI:1043760150
Name:ANTHONY, TRACEY
Entity Type:Individual
Prefix:MRS
First Name:TRACEY
Middle Name:
Last Name:ANTHONY
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:TRACEY
Other - Middle Name:
Other - Last Name:JOHN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1000 MONTAUK HWY
Mailing Address - Street 2:
Mailing Address - City:WEST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11795-4927
Mailing Address - Country:US
Mailing Address - Phone:631-376-3000
Mailing Address - Fax:
Practice Address - Street 1:8268 164TH ST
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432-1121
Practice Address - Country:US
Practice Address - Phone:718-883-3070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-12
Last Update Date:2024-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant