Provider Demographics
NPI:1639541790
Name:SHERMAN, TRACEY LEE (PA-C)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:LEE
Last Name:SHERMAN
Suffix:
Gender:M
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 1:34 N KANAWHA ST
Mailing Address - Street 2:
Mailing Address - City:BUCKHANNON
Mailing Address - State:WV
Mailing Address - Zip Code:26201-2714
Mailing Address - Country:US
Mailing Address - Phone:304-473-2250
Mailing Address - Fax:304-472-1208
Practice Address - Street 1:34 N KANAWHA ST
Practice Address - Street 2:
Practice Address - City:BUCKHANNON
Practice Address - State:WV
Practice Address - Zip Code:26201-2714
Practice Address - Country:US
Practice Address - Phone:304-473-2250
Practice Address - Fax:304-472-1208
Is Sole Proprietor?:No
Enumeration Date:2015-10-28
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1954363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1954OtherWV PA LICENSE
WV770OtherWV PA LICENSE