Provider Demographics
NPI:1801194097
Name:HOLLEY, TRACY LYNN (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:LYNN
Last Name:HOLLEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:TRACY
Other - Middle Name:LYNN
Other - Last Name:HEPWORTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3838 S 700 E STE 300
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84106
Mailing Address - Country:US
Mailing Address - Phone:801-261-4988
Mailing Address - Fax:801-269-9425
Practice Address - Street 1:9844 S 1300 E STE 100
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84094-4600
Practice Address - Country:US
Practice Address - Phone:801-571-9433
Practice Address - Fax:801-572-5607
Is Sole Proprietor?:No
Enumeration Date:2011-03-11
Last Update Date:2015-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT343176-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant