Provider Demographics
NPI:1669777512
Name:STEVENSON, TRACI LYNN (DO,)
Entity type:Individual
Prefix:
First Name:TRACI
Middle Name:LYNN
Last Name:STEVENSON
Suffix:
Gender:F
Credentials:DO,
Other - Prefix:
Other - First Name:TRACI
Other - Middle Name:LYNN
Other - Last Name:MOSHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:1310 CLUB DR STE 109
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94592-1189
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 HARTLE CT
Practice Address - Street 2:
Practice Address - City:NAPA
Practice Address - State:CA
Practice Address - Zip Code:94559-4078
Practice Address - Country:US
Practice Address - Phone:707-254-1775
Practice Address - Fax:707-254-1779
Is Sole Proprietor?:No
Enumeration Date:2011-01-24
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDOS1369207Q00000X
CA20A9911207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine