Provider Demographics
NPI:1760444202
Name:KIRKLAND, TRACI L (PA)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:L
Last Name:KIRKLAND
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3024 HIGHWAY 121
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76021-4037
Mailing Address - Country:US
Mailing Address - Phone:817-494-5000
Mailing Address - Fax:817-494-5001
Practice Address - Street 1:3024 HIGHWAY 121
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76021-4037
Practice Address - Country:US
Practice Address - Phone:817-494-5000
Practice Address - Fax:817-494-5001
Is Sole Proprietor?:No
Enumeration Date:2006-04-03
Last Update Date:2012-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA02966363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8L9244Medicare PIN
TXP42541Medicare UPIN
TXTXB163628Medicare PIN
TXTXB163627Medicare PIN
TX8L9243Medicare PIN
TXTXB163626Medicare PIN
TX8K3839Medicare PIN