Provider Demographics
NPI:1083657480
Name:PENN, TRACY A (PA-C)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:A
Last Name:PENN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:TRACY
Other - Middle Name:ANN
Other - Last Name:CRAWFORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 989
Mailing Address - Street 2:604 EAKER ST. FRONTERA HEALTHCARE NETWORK, INC.
Mailing Address - City:EDEN
Mailing Address - State:TX
Mailing Address - Zip Code:76837
Mailing Address - Country:US
Mailing Address - Phone:325-869-5500
Mailing Address - Fax:325-869-5692
Practice Address - Street 1:2010 NINE ROAD
Practice Address - Street 2:REHAB. CENTER FRONTERA HEALTHCARE NETWORK, INC.
Practice Address - City:BRADY
Practice Address - State:TX
Practice Address - Zip Code:76825
Practice Address - Country:US
Practice Address - Phone:325-597-0102
Practice Address - Fax:325-597-2939
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2013-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04795363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q7172Medicare UPIN
07172Medicare UPIN