Provider Demographics
NPI:1770561995
Name:GOEN, TRACY HARRISON (MD)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:HARRISON
Last Name:GOEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 16337
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:VA
Mailing Address - Zip Code:24209-6337
Mailing Address - Country:US
Mailing Address - Phone:979-224-0717
Mailing Address - Fax:
Practice Address - Street 1:917 W WALNUT ST
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-6527
Practice Address - Country:US
Practice Address - Phone:423-439-6471
Practice Address - Fax:423-439-4320
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN47760207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
I23488Medicare UPIN