Provider Demographics
NPI:1972835973
Name:CONNELL, TRACEY RENEE (PA)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:RENEE
Last Name:CONNELL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:TRACEY
Other - Middle Name:RENEE
Other - Last Name:LIM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:5555 E ARAPAHOE RD
Mailing Address - Street 2:
Mailing Address - City:CENTENNIAL
Mailing Address - State:CO
Mailing Address - Zip Code:80122-2312
Mailing Address - Country:US
Mailing Address - Phone:303-338-4545
Mailing Address - Fax:
Practice Address - Street 1:5555 E ARAPAHOE RD
Practice Address - Street 2:
Practice Address - City:CENTENNIAL
Practice Address - State:CO
Practice Address - Zip Code:80122-2312
Practice Address - Country:US
Practice Address - Phone:303-338-4545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-02
Last Update Date:2012-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2950363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO020852OtherKAISER COMMERCIAL NUMBER
CO37355031Medicaid
CO020852OtherKAISER COMMERCIAL NUMBER