Provider Demographics
NPI:1235253006
Name:FRIEDMAN, TRACY (PA)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:FRIEDMAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 GORDON DR
Mailing Address - Street 2:
Mailing Address - City:EXTON
Mailing Address - State:PA
Mailing Address - Zip Code:19341-1252
Mailing Address - Country:US
Mailing Address - Phone:610-594-6660
Mailing Address - Fax:610-594-6810
Practice Address - Street 1:501 GORDON DR
Practice Address - Street 2:
Practice Address - City:EXTON
Practice Address - State:PA
Practice Address - Zip Code:19341-1252
Practice Address - Country:US
Practice Address - Phone:610-594-6660
Practice Address - Fax:610-594-6810
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2014-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA056792363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000832411EMedicaid
GA000832411CMedicaid
GA000832411EMedicaid
GAQ45041Medicare UPIN