Provider Demographics
NPI:1609109024
Name:SMITH, TRACY MARIE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:TRACY
Middle Name:MARIE
Last Name:SMITH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:MARIE
Other - Last Name:LAZUR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:260 CALLE CAMPESINO
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92672-4553
Mailing Address - Country:US
Mailing Address - Phone:949-366-1053
Mailing Address - Fax:949-544-7880
Practice Address - Street 1:4190 CITY AVE
Practice Address - Street 2:SUITE 528
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19131-1626
Practice Address - Country:US
Practice Address - Phone:866-453-8800
Practice Address - Fax:844-734-7689
Is Sole Proprietor?:No
Enumeration Date:2009-09-16
Last Update Date:2015-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA054091363AM0700X
CAPA21436363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical