Provider Demographics
NPI:1417984410
Name:LIM, TRACY DANG (PAC)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:DANG
Last Name:LIM
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 E HOLT AVE
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-5426
Mailing Address - Country:US
Mailing Address - Phone:909-629-8088
Mailing Address - Fax:909-629-8755
Practice Address - Street 1:1420 S CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-2508
Practice Address - Country:US
Practice Address - Phone:818-502-2344
Practice Address - Fax:818-502-4501
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-26
Last Update Date:2014-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA18103363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA18103Medicaid
CAWPA18103AMedicare PIN
CAPA18103Medicaid
CAWPA18103CMedicare PIN
CAQ67587Medicare UPIN