Provider Demographics
NPI:1881675015
Name:WILCOX, TRACEY LYNN (PA-C)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:LYNN
Last Name:WILCOX
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5005 RUSTON WAY
Mailing Address - Street 2:STE 125
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98402-5314
Mailing Address - Country:US
Mailing Address - Phone:253-759-4522
Mailing Address - Fax:253-759-4699
Practice Address - Street 1:5005 RUSTON WAY
Practice Address - Street 2:STE 125
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402-5314
Practice Address - Country:US
Practice Address - Phone:253-759-4522
Practice Address - Fax:253-759-4699
Is Sole Proprietor?:No
Enumeration Date:2005-11-05
Last Update Date:2015-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9102446363AM0700X
WA60413586363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2916622000Medicaid
WA336140OtherSTATE L&I
WA336140OtherSTATE L&I
WAG8925854Medicare PIN