Provider Demographics
NPI:1336355387
Name:RYAN, TRACI (DO)
Entity Type:Individual
Prefix:DR
First Name:TRACI
Middle Name:
Last Name:RYAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:TRACI
Other - Middle Name:
Other - Last Name:ANSELMO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:7218 BUCKS FORD DR
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33578-8378
Mailing Address - Country:US
Mailing Address - Phone:215-828-4242
Mailing Address - Fax:
Practice Address - Street 1:119 OAKFIELD DR
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5779
Practice Address - Country:US
Practice Address - Phone:813-581-5150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2014-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS012467207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine