Provider Demographics
NPI:1205814662
Name:TRACY, JOANN M (PAC)
Entity Type:Individual
Prefix:MRS
First Name:JOANN
Middle Name:M
Last Name:TRACY
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:915 NE VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:PULLMAN
Mailing Address - State:WA
Mailing Address - Zip Code:99163-3845
Mailing Address - Country:US
Mailing Address - Phone:509-332-3548
Mailing Address - Fax:509-332-5253
Practice Address - Street 1:915 NE VALLEY RD
Practice Address - Street 2:
Practice Address - City:PULLMAN
Practice Address - State:WA
Practice Address - Zip Code:99163
Practice Address - Country:US
Practice Address - Phone:509-332-3548
Practice Address - Fax:509-332-5253
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2010-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10003597363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1823905Medicaid
S59126Medicare UPIN
WA1823905Medicaid