Provider Demographics
NPI:1659643385
Name:WOOD, TRACI LYNN (PA-C)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:LYNN
Last Name:WOOD
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 1:127 S. 500 E
Mailing Address - Street 2:SUITE 600
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-1971
Mailing Address - Country:US
Mailing Address - Phone:801-587-6336
Mailing Address - Fax:801-715-8228
Practice Address - Street 1:196 E 2000 N
Practice Address - Street 2:SUITE 100
Practice Address - City:TOOELE
Practice Address - State:UT
Practice Address - Zip Code:84074-9335
Practice Address - Country:US
Practice Address - Phone:435-882-7644
Practice Address - Fax:435-882-2284
Is Sole Proprietor?:No
Enumeration Date:2012-01-26
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8187126-1206363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant