Provider Demographics
NPI:1598766354
Name:VAUGHN, TRACY A (RPA)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:A
Last Name:VAUGHN
Suffix:
Gender:F
Credentials:RPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4507A MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13066-6616
Mailing Address - Country:US
Mailing Address - Phone:315-663-0508
Mailing Address - Fax:315-663-0509
Practice Address - Street 1:4507A MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NY
Practice Address - Zip Code:13066-6604
Practice Address - Country:US
Practice Address - Phone:315-663-0508
Practice Address - Fax:315-663-0509
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2013-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006835363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYPA0231Medicare ID - Type Unspecified
NYS76090Medicare UPIN