Provider Demographics
NPI:1942260476
Name:TRACY, JAY FRANCIS (PA-C, PSYD, LP)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:FRANCIS
Last Name:TRACY
Suffix:
Gender:M
Credentials:PA-C, PSYD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3915 GOLDEN VALLEY RD
Mailing Address - Street 2:COURAGE CENTER
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55422
Mailing Address - Country:US
Mailing Address - Phone:612-588-0811
Mailing Address - Fax:763-520-0355
Practice Address - Street 1:3915 GOLDEN VALLEY RD
Practice Address - Street 2:COURAGE CENTER
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55422
Practice Address - Country:US
Practice Address - Phone:612-588-0811
Practice Address - Fax:763-520-0355
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8827363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S67393Medicare UPIN