Provider Demographics
NPI:1477720423
Name:MULDER, TRACY L (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:L
Last Name:MULDER
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:L
Other - Last Name:MOLLAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1848
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49443-1848
Mailing Address - Country:US
Mailing Address - Phone:616-685-8250
Mailing Address - Fax:616-532-3564
Practice Address - Street 1:3380 44TH ST SW
Practice Address - Street 2:
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418-2461
Practice Address - Country:US
Practice Address - Phone:616-685-8250
Practice Address - Fax:616-532-3564
Is Sole Proprietor?:No
Enumeration Date:2008-05-09
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005272363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0M74460009Medicare PIN