Provider Demographics
NPI:1114179637
Name:BEVILAQUA-TRACY, KELLY ANN (PA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:BEVILAQUA-TRACY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
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Mailing Address - Street 1:100 N ACADEMY AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17822-4903
Mailing Address - Country:US
Mailing Address - Phone:570-271-6144
Mailing Address - Fax:570-271-6578
Practice Address - Street 1:1800 MULBERRY ST
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18510-2369
Practice Address - Country:US
Practice Address - Phone:570-703-4830
Practice Address - Fax:570-703-4835
Is Sole Proprietor?:No
Enumeration Date:2008-10-15
Last Update Date:2020-12-30
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
PAMA053585363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant