Provider Demographics
NPI:1780043174
Name:JOHN, TRACEY (PA-C)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:
Last Name:JOHN
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 1:44572 W. BOWLIN ROAD
Mailing Address - Street 2:
Mailing Address - City:MARICOPA
Mailing Address - State:AZ
Mailing Address - Zip Code:85138-8922
Mailing Address - Country:US
Mailing Address - Phone:480-216-9417
Mailing Address - Fax:
Practice Address - Street 1:44572 W. BOWLIN ROAD
Practice Address - Street 2:
Practice Address - City:MARICOPA
Practice Address - State:AZ
Practice Address - Zip Code:85138-8922
Practice Address - Country:US
Practice Address - Phone:480-216-9417
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6316363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ114369Medicaid