Provider Demographics
NPI:1396878922
Name:LIBERATORE, TRACY LYNN (PA-C)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:LYNN
Last Name:LIBERATORE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 MUNDY ST
Mailing Address - Street 2:MAC IV BUILDING
Mailing Address - City:WILKES BARRE
Mailing Address - State:PA
Mailing Address - Zip Code:18702-6830
Mailing Address - Country:US
Mailing Address - Phone:570-824-0930
Mailing Address - Fax:570-824-7755
Practice Address - Street 1:150 MUNDY ST
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18702-6830
Practice Address - Country:US
Practice Address - Phone:570-824-0930
Practice Address - Fax:570-824-7755
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA051327363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAP00388511OtherRAILROAD MEDICARE
PAP00388511OtherRAILROAD MEDICARE