Provider Demographics
NPI:1083024467
Name:SMYTHE, TRACY MOREY MARIANI (PA)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:MOREY MARIANI
Last Name:SMYTHE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1668 DOMINICAN WAY
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95065-1522
Mailing Address - Country:US
Mailing Address - Phone:831-464-9962
Mailing Address - Fax:831-464-9933
Practice Address - Street 1:1668 DOMINICAN WAY
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95065-1522
Practice Address - Country:US
Practice Address - Phone:831-464-9962
Practice Address - Fax:831-464-9933
Is Sole Proprietor?:No
Enumeration Date:2014-05-06
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA54516363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical