Provider Demographics
NPI:1134118573
Name:HYDORN, TRACY HELEN (PA-C)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:HELEN
Last Name:HYDORN
Suffix:
Gender:F
Credentials: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:PO BOX 2393
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:CA
Mailing Address - Zip Code:93921-2393
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:201 9TH ST
Practice Address - Street 2:
Practice Address - City:MARINA
Practice Address - State:CA
Practice Address - Zip Code:93933-6039
Practice Address - Country:US
Practice Address - Phone:831-884-1172
Practice Address - Fax:831-884-1033
Is Sole Proprietor?:No
Enumeration Date:2005-10-18
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA 13055363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA970008050OtherRAILROAD MEDICARE
CAPA13055Medicaid
CA0PA130552Medicare PIN
CA970008050OtherRAILROAD MEDICARE
CA0PA130551Medicare PIN