Provider Demographics
NPI:1740402379
Name:WALKER, TRACY H (FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:H
Last Name:WALKER
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:739 IRVING AVE
Mailing Address - Street 2:SUITE 450
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-1651
Mailing Address - Country:US
Mailing Address - Phone:315-470-7364
Mailing Address - Fax:
Practice Address - Street 1:739 IRVING AVE
Practice Address - Street 2:SUITE 450
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-1651
Practice Address - Country:US
Practice Address - Phone:315-470-7364
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY567744163W00000X
NY337389363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02723733Medicaid