Provider Demographics
NPI:1376820266
Name:DYER, TRACI LEE (PA)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:LEE
Last Name:DYER
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 1:28853 GALAXY WAY
Mailing Address - Street 2:
Mailing Address - City:SUN CITY
Mailing Address - State:CA
Mailing Address - Zip Code:92586-3869
Mailing Address - Country:US
Mailing Address - Phone:951-852-6653
Mailing Address - Fax:951-301-3980
Practice Address - Street 1:29798 HAUN RD STE 108
Practice Address - Street 2:
Practice Address - City:SUN CITY
Practice Address - State:CA
Practice Address - Zip Code:92586-6541
Practice Address - Country:US
Practice Address - Phone:951-301-9339
Practice Address - Fax:951-301-3980
Is Sole Proprietor?:No
Enumeration Date:2011-11-07
Last Update Date:2011-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19684363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical