Provider Demographics
NPI:1184626996
Name:CROCKETT, TRACY (PA)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:CROCKETT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1131 GOLF COURSE LN
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30605-5350
Mailing Address - Country:US
Mailing Address - Phone:706-613-1518
Mailing Address - Fax:
Practice Address - Street 1:2470 DANIELS BRIDGE RD
Practice Address - Street 2:BLDG 200 SUITE 251
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-6187
Practice Address - Country:US
Practice Address - Phone:706-389-3440
Practice Address - Fax:706-353-2771
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2013-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1763363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA100000351CMedicaid
P37418Medicare UPIN
GA100000351CMedicaid