Provider Demographics
NPI:1851748370
Name:TRACY, KERANI A (MD)
Entity Type:Individual
Prefix:
First Name:KERANI
Middle Name:A
Last Name:TRACY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KERANI
Other - Middle Name:A
Other - Last Name:MCCLELLAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5050 NE HOYT ST STE 454
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-2984
Practice Address - Country:US
Practice Address - Phone:503-215-6405
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-16
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD196285207Q00000X, 207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program