Provider Demographics
NPI:1053310250
Name:EARL, TRACY IVAN (PA)
Entity Type:Individual
Prefix:MR
First Name:TRACY
Middle Name:IVAN
Last Name:EARL
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:36 14TH AVE NE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:HICKORY
Mailing Address - State:NC
Mailing Address - Zip Code:28601-2580
Mailing Address - Country:US
Mailing Address - Phone:828-345-6468
Mailing Address - Fax:828-345-1468
Practice Address - Street 1:36 14TH AVE NE
Practice Address - Street 2:SUITE 103
Practice Address - City:HICKORY
Practice Address - State:NC
Practice Address - Zip Code:28601-2580
Practice Address - Country:US
Practice Address - Phone:828-345-6468
Practice Address - Fax:828-345-1468
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2011-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-01786363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC154755OtherNORTH CAROLINA MEDICAL BOARD