Provider Demographics
NPI:1104855105
Name:DAU, TRACY V (PA)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:V
Last Name:DAU
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:
Other - Last Name:VOGEL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 13700-3765
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19191-3765
Mailing Address - Country:US
Mailing Address - Phone:610-668-6471
Mailing Address - Fax:610-617-6280
Practice Address - Street 1:718 TEANECK RD
Practice Address - Street 2:HOLY NAME HOSPITAL
Practice Address - City:TEANECK
Practice Address - State:NJ
Practice Address - Zip Code:07666
Practice Address - Country:US
Practice Address - Phone:201-833-3000
Practice Address - Fax:610-617-6280
Is Sole Proprietor?:No
Enumeration Date:2006-07-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00066100363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ057369Medicare ID - Type Unspecified
P12947Medicare UPIN