Provider Demographics
NPI:1396986360
Name:ELLISON, TRACI HARP (PA-C)
Entity type:Individual
Prefix:
First Name:TRACI
Middle Name:HARP
Last Name:ELLISON
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 1:4211 MONARCH WAY
Mailing Address - Street 2:STE 100
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23508-2540
Mailing Address - Country:US
Mailing Address - Phone:757-738-1400
Mailing Address - Fax:
Practice Address - Street 1:1201 LEOPARD ST FL 6
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78401-2120
Practice Address - Country:US
Practice Address - Phone:361-826-3333
Practice Address - Fax:361-826-3334
Is Sole Proprietor?:No
Enumeration Date:2009-03-20
Last Update Date:2018-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110002964363A00000X
TXPA08123363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA021641B09Medicare PIN