Provider Demographics
NPI:1124036520
Name:ALLEN, TRACY L (PA)
Entity Type:Individual
Prefix:MS
First Name:TRACY
Middle Name:L
Last Name:ALLEN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 RIVERSTONE VIS
Mailing Address - Street 2:SUITE 111
Mailing Address - City:BLUE RIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30513-6648
Mailing Address - Country:US
Mailing Address - Phone:706-946-4200
Mailing Address - Fax:706-946-4243
Practice Address - Street 1:101 RIVERSTONE VIS
Practice Address - Street 2:SUITE 111
Practice Address - City:BLUE RIDGE
Practice Address - State:GA
Practice Address - Zip Code:30513-6648
Practice Address - Country:US
Practice Address - Phone:706-946-4200
Practice Address - Fax:706-946-4243
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2014-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA-440363A00000X
GA005894363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003100897CMedicaid
GA202I978456Medicare PIN