Provider Demographics
NPI:1356667059
Name:MANDRYK, TRACY D (NP)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:D
Last Name:MANDRYK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1011 WATERBURY LN
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93001-3841
Mailing Address - Country:US
Mailing Address - Phone:805-766-2750
Mailing Address - Fax:
Practice Address - Street 1:1901 OUTLET CENTER DR
Practice Address - Street 2:SUITE 230
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93036-0663
Practice Address - Country:US
Practice Address - Phone:805-983-6233
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-20
Last Update Date:2012-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA388425163W00000X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP20859Medicare UPIN