Provider Demographics
NPI:1265624886
Name:TRAM, TRACY (PAC)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:TRAM
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1075 N ANTONIO CIR
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92869-1966
Mailing Address - Country:US
Mailing Address - Phone:714-785-5121
Mailing Address - Fax:
Practice Address - Street 1:14501 MAGNOLIA ST
Practice Address - Street 2:SUITE 104
Practice Address - City:WESTMINSTER
Practice Address - State:CA
Practice Address - Zip Code:92683-5542
Practice Address - Country:US
Practice Address - Phone:714-893-6008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-16
Last Update Date:2009-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
CAPA15234363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant