Provider Demographics
NPI:1578647277
Name:DAVIS, TRACY DENISE (PA-C)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:DENISE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:5243 RIVERSIDE DR
Mailing Address - Street 2:APT 2105
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-8803
Mailing Address - Country:US
Mailing Address - Phone:478-742-7566
Mailing Address - Fax:478-746-9944
Practice Address - Street 1:688 WALNUT ST
Practice Address - Street 2:SUITE 200
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-2677
Practice Address - Country:US
Practice Address - Phone:478-742-7566
Practice Address - Fax:478-746-9944
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA004461363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical