Provider Demographics
NPI:1184803090
Name:RACKLEY, TANYA MARIE (MD)
Entity type:Individual
Prefix:DR
First Name:TANYA
Middle Name:MARIE
Last Name:RACKLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:TANYA
Other - Middle Name:MARIE
Other - Last Name:MCGLOTHLIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:919 HIDDEN RDG
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75038-3813
Mailing Address - Country:US
Mailing Address - Phone:469-282-2711
Mailing Address - Fax:469-282-0996
Practice Address - Street 1:1345 ALAMO RANCH PKWY
Practice Address - Street 2:STE 203
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78253-6440
Practice Address - Country:US
Practice Address - Phone:210-767-4000
Practice Address - Fax:210-688-9418
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-26
Last Update Date:2017-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10021876208000000X
TXM8267208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX215387605Medicaid