Provider Demographics
NPI:1154501690
Name:TRACY, MARY A (PA-C)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:A
Last Name:TRACY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:A
Other - Last Name:SNIDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:307 S EVERGREEN AVE
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:NJ
Mailing Address - Zip Code:08096-2739
Mailing Address - Country:US
Mailing Address - Phone:856-686-4317
Mailing Address - Fax:
Practice Address - Street 1:427 GUY PARK AVE
Practice Address - Street 2:
Practice Address - City:AMSTERDAM
Practice Address - State:NY
Practice Address - Zip Code:12010-1054
Practice Address - Country:US
Practice Address - Phone:518-841-7237
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-13
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012195363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant