Provider Demographics
NPI:1588657662
Name:POSTON, TRACY SANDFORD (PAC)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:SANDFORD
Last Name:POSTON
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:
Other - Last Name:BOOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:3825 W MENADOTA DR
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-7425
Mailing Address - Country:US
Mailing Address - Phone:602-690-7479
Mailing Address - Fax:
Practice Address - Street 1:903 N 2ND ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85004-1906
Practice Address - Country:US
Practice Address - Phone:602-416-7600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2011-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2503363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Z144795OtherMEDICARE PTAN
AZWCLCJ70259Medicaid
AZ108740Medicare ID - Type Unspecified
Z144795OtherMEDICARE PTAN
AZWCLCJ70259Medicaid