Provider Demographics
NPI:1790107357
Name:SMITH, TRACEY LEE (PA-C)
Entity Type:Individual
Prefix:MR
First Name:TRACEY
Middle Name:LEE
Last Name:SMITH
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:7780 BRIER CREEK PARKWAY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27617-7869
Mailing Address - Country:US
Mailing Address - Phone:919-596-3400
Mailing Address - Fax:919-596-3499
Practice Address - Street 1:1970-C WEST ARLINGTON BLVD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27837-5783
Practice Address - Country:US
Practice Address - Phone:252-317-1195
Practice Address - Fax:919-317-1111
Is Sole Proprietor?:No
Enumeration Date:2014-01-15
Last Update Date:2014-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0090-01776363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S71595Medicare UPIN