Provider Demographics
NPI:1821024746
Name:HAZELTON, TRACY (PA)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:HAZELTON
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 1:15322 LAKESHORE DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CLEARLAKE
Mailing Address - State:CA
Mailing Address - Zip Code:95422-9814
Mailing Address - Country:US
Mailing Address - Phone:707-995-1362
Mailing Address - Fax:707-995-1362
Practice Address - Street 1:15322 LAKESHORE DR
Practice Address - Street 2:SUITE 101
Practice Address - City:CLEARLAKE
Practice Address - State:CA
Practice Address - Zip Code:95422-9814
Practice Address - Country:US
Practice Address - Phone:707-995-1362
Practice Address - Fax:707-995-1362
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2009-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA13690363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PA136900Medicare ID - Type Unspecified