Provider Demographics
NPI:1497056824
Name:ARSENAULT, TRACY MELINDA (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:MELINDA
Last Name:ARSENAULT
Suffix:
Gender:F
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 1:4980 BARRANCA PKWY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92604-8645
Mailing Address - Country:US
Mailing Address - Phone:949-786-5050
Mailing Address - Fax:
Practice Address - Street 1:4980 BARRANCA PKWY
Practice Address - Street 2:SUITE 200
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92604-8645
Practice Address - Country:US
Practice Address - Phone:949-786-5050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-17
Last Update Date:2014-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-003952363AM0700X, 363AS0400X
WI2708-023363AS0400X
IN10001255A363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01618941OtherBLUECROSS BLUESHIELD
IL01618941OtherBLUECROSS BLUESHIELD
ILT01332Medicare PIN
ILT01333Medicare PIN