Provider Demographics
NPI:1568537181
Name:FAIR-PARSONS, TRACY L (PA-C)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:L
Last Name:FAIR-PARSONS
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:PO BOX 2580
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65801-2580
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:417-829-4316
Practice Address - Street 1:1605 MARTIN SPRINGS DR
Practice Address - Street 2:STE 210
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-2931
Practice Address - Country:US
Practice Address - Phone:573-458-6326
Practice Address - Fax:573-458-6763
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2011-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO110764363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000097116Medicare PIN
MOP88646Medicare UPIN