Provider Demographics
NPI:1467671453
Name:MCTIERNAN, TRACY LYNNE (PNP)
Entity Type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:LYNNE
Last Name:MCTIERNAN
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:292 HART AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10310-3024
Mailing Address - Country:US
Mailing Address - Phone:718-816-8768
Mailing Address - Fax:
Practice Address - Street 1:530 1ST AVE
Practice Address - Street 2:SUITE 10 W
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-6402
Practice Address - Country:US
Practice Address - Phone:212-263-7391
Practice Address - Fax:212-263-6590
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-25
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF381220363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02091867Medicaid