Provider Demographics
NPI:1568590669
Name:BLAKE-DIXON, TRACEY MONIQUE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:TRACEY
Middle Name:MONIQUE
Last Name:BLAKE-DIXON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:TRACEY
Other - Middle Name:MONIQUE
Other - Last Name:DIXON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:75 DUNSTON AVE
Mailing Address - Street 2:
Mailing Address - City:YONKERS
Mailing Address - State:NY
Mailing Address - Zip Code:10701-6322
Mailing Address - Country:US
Mailing Address - Phone:914-420-9168
Mailing Address - Fax:
Practice Address - Street 1:264 W 118TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10026-1620
Practice Address - Country:US
Practice Address - Phone:914-420-9168
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2015-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005757-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant