Provider Demographics
NPI:1730500869
Name:LYONS-WHITE, TRACEY MICHELLE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:TRACEY
Middle Name:MICHELLE
Last Name:LYONS-WHITE
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 1:325 TAYLOR ST UNIT 2051
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201-6022
Mailing Address - Country:US
Mailing Address - Phone:646-276-4597
Mailing Address - Fax:
Practice Address - Street 1:145 PARK CENTRAL DR STE 100
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6469
Practice Address - Country:US
Practice Address - Phone:803-736-3277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-16
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1115674363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant