Provider Demographics
NPI:1740231257
Name:MARCHETTA, TRACY (PA-C)
Entity type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:
Last Name:MARCHETTA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:TRACY
Other - Middle Name:
Other - Last Name:WILDONER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:514 LIPPINCOTT DR
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-4803
Mailing Address - Country:US
Mailing Address - Phone:856-988-8080
Mailing Address - Fax:856-596-3179
Practice Address - Street 1:514 LIPPINCOTT DR
Practice Address - Street 2:
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-4803
Practice Address - Country:US
Practice Address - Phone:856-988-8080
Practice Address - Fax:856-596-3179
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2011-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00107700207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJQ23642Medicare UPIN
NJ083227C2HMedicare ID - Type Unspecified