Provider Demographics
NPI:1164592275
Name:CLONINGER, TRACEY S (PA-C)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:S
Last Name:CLONINGER
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 1:4201 LAKE BOONE TRL
Mailing Address - Street 2:SUITE 200
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-7511
Mailing Address - Country:US
Mailing Address - Phone:919-782-2152
Mailing Address - Fax:919-782-7929
Practice Address - Street 1:4201 LAKE BOONE TRL
Practice Address - Street 2:SUITE 200
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-7511
Practice Address - Country:US
Practice Address - Phone:919-782-2152
Practice Address - Fax:919-782-7929
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2012-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103242363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP70380Medicare UPIN
2756077AMedicare PIN