Provider Demographics
NPI:1295914786
Name:NWAJUAKU, TRACY (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:MISS
First Name:TRACY
Middle Name:
Last Name:NWAJUAKU
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6316 HOLMES AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90001-1824
Mailing Address - Country:US
Mailing Address - Phone:323-583-5887
Mailing Address - Fax:323-583-6601
Practice Address - Street 1:6316 HOLMES AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90001-1824
Practice Address - Country:US
Practice Address - Phone:323-583-5887
Practice Address - Fax:323-583-6601
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-31
Last Update Date:2012-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA1076110363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA1076110Medicaid