Provider Demographics
NPI:1376829184
Name:MAHONEY, TRACI L (PA)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:L
Last Name:MAHONEY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:TRACI
Other - Middle Name:LYNN
Other - Last Name:BALDWIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:300 HICKMAN RD STE 202
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22911-3554
Mailing Address - Country:US
Mailing Address - Phone:434-326-5815
Mailing Address - Fax:434-326-5820
Practice Address - Street 1:545 RAY C HUNT DR STE 140
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22903
Practice Address - Country:US
Practice Address - Phone:434-243-0245
Practice Address - Fax:434-243-0242
Is Sole Proprietor?:No
Enumeration Date:2011-10-25
Last Update Date:2023-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110006132363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1376829184Medicaid
NY03427667Medicaid