Provider Demographics
NPI:1689197113
Name:TRACY, SHANE (PA-C)
Entity Type:Individual
Prefix:MR
First Name:SHANE
Middle Name:
Last Name:TRACY
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 1:2780 E BARNETT RD STE 200
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-8674
Mailing Address - Country:US
Mailing Address - Phone:541-779-6250
Mailing Address - Fax:541-608-2535
Practice Address - Street 1:2780 E BARNETT RD STE 200
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504
Practice Address - Country:US
Practice Address - Phone:541-779-6250
Practice Address - Fax:541-608-2535
Is Sole Proprietor?:No
Enumeration Date:2017-07-17
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA187850363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant