Provider Demographics
NPI:1629056817
Name:HAMMOND, TRACIE L (PA-C)
Entity Type:Individual
Prefix:MS
First Name:TRACIE
Middle Name:L
Last Name:HAMMOND
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 1:192 TILLEY DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05403-4440
Mailing Address - Country:US
Mailing Address - Phone:802-847-2663
Mailing Address - Fax:802-847-1718
Practice Address - Street 1:192 TILLEY DR
Practice Address - Street 2:
Practice Address - City:SOUTH BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403-4440
Practice Address - Country:US
Practice Address - Phone:802-847-2663
Practice Address - Fax:802-847-1718
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2013-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT055-0031153363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT9000239Medicaid
VT9000239Medicaid
VTAP2500Medicare ID - Type Unspecified