Provider Demographics
NPI:1821417320
Name:MYERS, TRACY PEARL (C-AGNP)
Entity Type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:PEARL
Last Name:MYERS
Suffix:
Gender:F
Credentials:C-AGNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12960 SHORTLINE HWY
Mailing Address - Street 2:
Mailing Address - City:PINE GROVE
Mailing Address - State:WV
Mailing Address - Zip Code:26419-8221
Mailing Address - Country:US
Mailing Address - Phone:304-889-3344
Mailing Address - Fax:304-889-3366
Practice Address - Street 1:12960 SHORTLINE HWY
Practice Address - Street 2:
Practice Address - City:PINE GROVE
Practice Address - State:WV
Practice Address - Zip Code:26419-8221
Practice Address - Country:US
Practice Address - Phone:304-889-3344
Practice Address - Fax:304-889-3366
Is Sole Proprietor?:No
Enumeration Date:2014-04-11
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVAPRN53866NP363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1821217320OtherUNKNOWN