Provider Demographics
NPI:1922094853
Name:EVANS, TRACY A (PA-C)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:A
Last Name:EVANS
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 1:725 RESERVOIR AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02910-4448
Mailing Address - Country:US
Mailing Address - Phone:401-944-3800
Mailing Address - Fax:401-944-1342
Practice Address - Street 1:2138 MENDON RD
Practice Address - Street 2:SUITE 302
Practice Address - City:CUMBERLAND
Practice Address - State:RI
Practice Address - Zip Code:02864-3834
Practice Address - Country:US
Practice Address - Phone:401-334-1060
Practice Address - Fax:401-334-1063
Is Sole Proprietor?:No
Enumeration Date:2005-09-26
Last Update Date:2016-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RICPA00245363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI2036OtherBC
RI408249OtherBLUE CHIP
RI7008740Medicaid
RI1922094853OtherDURABLE
RI408249OtherBLUE CHIP
RI007008740Medicare PIN