Provider Demographics
NPI:1568779155
Name:MARTINO, TRACY MCWHORTER (PA-C)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:MCWHORTER
Last Name:MARTINO
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 1:3 PROFESSIONAL PARK DR STE 21
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-6529
Mailing Address - Country:US
Mailing Address - Phone:423-434-6300
Mailing Address - Fax:423-434-6312
Practice Address - Street 1:3 PROFESSIONAL PARK DR STE 21
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-6529
Practice Address - Country:US
Practice Address - Phone:423-434-6300
Practice Address - Fax:423-434-6312
Is Sole Proprietor?:No
Enumeration Date:2010-09-03
Last Update Date:2019-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3610363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002807800Medicaid
FLDU085ZMedicare PIN