Provider Demographics
NPI:1336128883
Name:DARNELL, TRACI DENISE (PA C)
Entity Type:Individual
Prefix:MRS
First Name:TRACI
Middle Name:DENISE
Last Name:DARNELL
Suffix:
Gender:F
Credentials:PA C
Other - Prefix:MS
Other - First Name:TRACI
Other - Middle Name:DENISE
Other - Last Name:PHELPS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:497 WEST LOTT
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:WY
Mailing Address - Zip Code:82834-1609
Mailing Address - Country:US
Mailing Address - Phone:307-684-2228
Mailing Address - Fax:307-684-2177
Practice Address - Street 1:497 W LOTT ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:WY
Practice Address - Zip Code:82834-1609
Practice Address - Country:US
Practice Address - Phone:307-684-2228
Practice Address - Fax:307-684-2177
Is Sole Proprietor?:No
Enumeration Date:2006-01-12
Last Update Date:2007-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY280363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY11811730Medicaid
WY313751OtherBLUE CROSS
WYW20462Medicare ID - Type Unspecified
WY313751OtherBLUE CROSS