Provider Demographics
NPI:1689617938
Name:SERRATO, TRACIE A (PA)
Entity Type:Individual
Prefix:MS
First Name:TRACIE
Middle Name:A
Last Name:SERRATO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:TRACIE
Other - Middle Name:A
Other - Last Name:FEAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:215 S HICKORY ST STE 114
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92025-4360
Mailing Address - Country:US
Mailing Address - Phone:760-704-9429
Mailing Address - Fax:
Practice Address - Street 1:2386 FARADAY AVE
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92008-7221
Practice Address - Country:US
Practice Address - Phone:619-320-5150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA57495363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ045203Medicaid
AZZ112231Medicare PIN