Provider Demographics
NPI:1851538789
Name:GILLAN, TRACEY (NP)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:
Last Name:GILLAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3001 EXPRESSWAY DR N
Mailing Address - Street 2:
Mailing Address - City:ISLANDIA
Mailing Address - State:NY
Mailing Address - Zip Code:11749-5301
Mailing Address - Country:US
Mailing Address - Phone:631-444-3497
Mailing Address - Fax:631-444-1530
Practice Address - Street 1:3001 EXPRESSWAY DR N
Practice Address - Street 2:
Practice Address - City:ISLANDIA
Practice Address - State:NY
Practice Address - Zip Code:11749-5301
Practice Address - Country:US
Practice Address - Phone:631-444-3497
Practice Address - Fax:631-444-1530
Is Sole Proprietor?:No
Enumeration Date:2009-01-14
Last Update Date:2009-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY302471363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health