Provider Demographics
NPI:1700975539
Name:BARILLA, TRACY (RPAC)
Entity Type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:
Last Name:BARILLA
Suffix:
Gender:F
Credentials:RPAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17660 UNION TPKE
Mailing Address - Street 2:STE 360
Mailing Address - City:FRESH MEADOWS
Mailing Address - State:NY
Mailing Address - Zip Code:11366-1526
Mailing Address - Country:US
Mailing Address - Phone:718-460-2300
Mailing Address - Fax:718-460-9697
Practice Address - Street 1:17660 UNION TPKE
Practice Address - Street 2:STE 360
Practice Address - City:FRESH MEADOWS
Practice Address - State:NY
Practice Address - Zip Code:11366-1526
Practice Address - Country:US
Practice Address - Phone:718-460-2300
Practice Address - Fax:718-460-9697
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2009-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011528363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY011582OtherLICENSE