Provider Demographics
NPI:1174681027
Name:PAIGE, TRACI LEIGH (DO)
Entity Type:Individual
Prefix:DR
First Name:TRACI
Middle Name:LEIGH
Last Name:PAIGE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4545 E CHANDLER BLVD
Mailing Address - Street 2:SUITE 206
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85048-7643
Mailing Address - Country:US
Mailing Address - Phone:480-961-5956
Mailing Address - Fax:
Practice Address - Street 1:4545 E CHANDLER BLVD
Practice Address - Street 2:SUITE 206
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85048-7643
Practice Address - Country:US
Practice Address - Phone:480-961-5956
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2011-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2959207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZG17526Medicare UPIN
AZ71307Medicare ID - Type UnspecifiedINDIVIDUAL MEDICARE #