Provider Demographics
NPI:1093159311
Name:YEARY, TRACY
Entity Type:Individual
Prefix:MR
First Name:TRACY
Middle Name:
Last Name:YEARY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1474 WOODSIDE ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:MI
Mailing Address - Zip Code:48161-1755
Mailing Address - Country:US
Mailing Address - Phone:734-693-2457
Mailing Address - Fax:
Practice Address - Street 1:1001 S RAISINVILLE RD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48161-9754
Practice Address - Country:US
Practice Address - Phone:734-243-7340
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-18
Last Update Date:2013-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker