Provider Demographics
NPI:1275911083
Name:ECHUCK, TRACY C (PA)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:C
Last Name:ECHUCK
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 1:9035 KELLY BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:DAWSONVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30534-4955
Mailing Address - Country:US
Mailing Address - Phone:770-480-1311
Mailing Address - Fax:
Practice Address - Street 1:9035 KELLY BRIDGE RD
Practice Address - Street 2:
Practice Address - City:DAWSONVILLE
Practice Address - State:GA
Practice Address - Zip Code:30534-4955
Practice Address - Country:US
Practice Address - Phone:770-480-1311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-13
Last Update Date:2020-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA153136246ZC0007X
GA151286246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
No246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist