Provider Demographics
NPI:1841241957
Name:ST JOHN, TRACEY
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:
Last Name:ST JOHN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:APO
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09356-9997
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:APO
Practice Address - Street 2:
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09356-9997
Practice Address - Country:US
Practice Address - Phone:200-270-6223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-13
Last Update Date:2012-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPA30020363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S97186Medicare UPIN