Provider Demographics
NPI:1235760356
Name:CUMMINS, TRACI TARVER (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:TRACI
Middle Name:TARVER
Last Name:CUMMINS
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 1:805 DUNTON RD
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MS
Mailing Address - Zip Code:39056-4307
Mailing Address - Country:US
Mailing Address - Phone:662-719-9770
Mailing Address - Fax:
Practice Address - Street 1:1400 E UNION ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MS
Practice Address - Zip Code:38703-3246
Practice Address - Country:US
Practice Address - Phone:662-378-3783
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-28
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPA00470363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant