Provider Demographics
NPI:1346269347
Name:PERKINS, TRACY BOLLER (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:BOLLER
Last Name:PERKINS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11800 SUNRISE VALLEY DR FL 8
Mailing Address - Street 2:
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20191-5300
Mailing Address - Country:US
Mailing Address - Phone:703-709-1114
Mailing Address - Fax:703-709-1117
Practice Address - Street 1:11800 SUNRISE VALLEY DR STE 800
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20191
Practice Address - Country:US
Practice Address - Phone:703-709-1114
Practice Address - Fax:703-709-1117
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2018-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110001624363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA013437N34Medicare UPIN