Provider Demographics
NPI:1235193392
Name:TRACY, TANYA WAGERS (MPT)
Entity Type:Individual
Prefix:MRS
First Name:TANYA
Middle Name:WAGERS
Last Name:TRACY
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3525 CAMEO DR
Mailing Address - Street 2:UNIT 89
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92056-6390
Mailing Address - Country:US
Mailing Address - Phone:573-644-4260
Mailing Address - Fax:
Practice Address - Street 1:4765 CARMEL MOUNTAIN RD
Practice Address - Street 2:SUITE 202
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92130-6657
Practice Address - Country:US
Practice Address - Phone:858-847-0055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2011-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29005225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist