Provider Demographics
NPI:1942286893
Name:ATHA, TRACY H (DC)
Entity Type:Individual
Prefix:DR
First Name:TRACY
Middle Name:H
Last Name:ATHA
Suffix:
Gender:F
Credentials:DC
Other - Prefix:DR
Other - First Name:TRACY
Other - Middle Name:H
Other - Last Name:MATTHEW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:5601 DUNCAN RD
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903-3211
Mailing Address - Country:US
Mailing Address - Phone:479-649-9422
Mailing Address - Fax:479-649-9515
Practice Address - Street 1:5601 DUNCAN RD
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-3211
Practice Address - Country:US
Practice Address - Phone:479-649-9422
Practice Address - Fax:479-649-9515
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-21
Last Update Date:2013-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1277111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARU12973Medicare UPIN
AR59133Medicare ID - Type Unspecified