Provider Demographics
NPI:1093812182
Name:REYNOLDS, TRACIE J (MS, PA-C)
Entity Type:Individual
Prefix:
First Name:TRACIE
Middle Name:J
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:MS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2006 HOLTON RD STE 500
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49445-1505
Mailing Address - Country:US
Mailing Address - Phone:231-370-1280
Mailing Address - Fax:
Practice Address - Street 1:2006 HOLTON RD STE 500
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49445-1505
Practice Address - Country:US
Practice Address - Phone:231-370-1280
Practice Address - Fax:231-672-7886
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5601003702363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP35450011Medicare PIN
MIQ41654Medicare UPIN