Provider Demographics
NPI:1699028092
Name:LONG, TRACI BUTLER (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:TRACI
Middle Name:BUTLER
Last Name:LONG
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:TRACI
Other - Middle Name:LYNN
Other - Last Name:BUTLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:61 BONNIE LN
Mailing Address - Street 2:
Mailing Address - City:SYLVA
Mailing Address - State:NC
Mailing Address - Zip Code:28779-8511
Mailing Address - Country:US
Mailing Address - Phone:828-631-1852
Mailing Address - Fax:828-631-2534
Practice Address - Street 1:61 BONNIE LN
Practice Address - Street 2:
Practice Address - City:SYLVA
Practice Address - State:NC
Practice Address - Zip Code:28779-8511
Practice Address - Country:US
Practice Address - Phone:828-631-1852
Practice Address - Fax:828-631-2534
Is Sole Proprietor?:No
Enumeration Date:2012-10-23
Last Update Date:2012-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-03884363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant