Provider Demographics
NPI:1467750604
Name:TRACY, DEVIN (PA-C)
Entity Type:Individual
Prefix:
First Name:DEVIN
Middle Name:
Last Name:TRACY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 30180
Mailing Address - Street 2:SUITE 600
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84130-0180
Mailing Address - Country:US
Mailing Address - Phone:801-920-5813
Mailing Address - Fax:
Practice Address - Street 1:805 E 2ND ST STE 3
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-2641
Practice Address - Country:US
Practice Address - Phone:307-237-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-12
Last Update Date:2016-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5959165-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant