Provider Demographics
NPI:1710934799
Name:COY, TRACY S (PAC)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:S
Last Name:COY
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:S
Other - Last Name:GOODMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3131 NEWMARK DR STE 220
Mailing Address - Street 2:
Mailing Address - City:MIAMISBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45342-5400
Mailing Address - Country:US
Mailing Address - Phone:937-436-4658
Mailing Address - Fax:937-436-4984
Practice Address - Street 1:3535 SOUTHERN BLVD
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-1221
Practice Address - Country:US
Practice Address - Phone:937-298-4331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50000637363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0078928Medicaid
OHH061071OtherMEDICARE PTAN
OH0078928Medicaid
OHH061070OtherMEDICARE PTAN