Provider Demographics
NPI:1760481188
Name:REILY, TRACEY K (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:TRACEY
Middle Name:K
Last Name:REILY
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 1:5959 S SHERWOOD FOREST BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-6038
Mailing Address - Country:US
Mailing Address - Phone:225-526-0011
Mailing Address - Fax:225-765-9196
Practice Address - Street 1:18901 GREENWELL SPRINGS RD
Practice Address - Street 2:
Practice Address - City:GREENWELL SPRINGS
Practice Address - State:LA
Practice Address - Zip Code:70739-4827
Practice Address - Country:US
Practice Address - Phone:225-924-9985
Practice Address - Fax:225-924-0884
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2021-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAA10554363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAP87715Medicare UPIN
LA5D279P430Medicare ID - Type Unspecified