Provider Demographics
NPI:1790136554
Name:WHELAN, TRACY ANN (PA-C)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:ANN
Last Name:WHELAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:ANN
Other - Last Name:RIESENBERGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1035 116TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-4604
Mailing Address - Country:US
Mailing Address - Phone:425-688-5000
Mailing Address - Fax:
Practice Address - Street 1:4755 OGLETOWN STANTON RD STE 2670
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19718-5803
Practice Address - Country:US
Practice Address - Phone:302-733-2438
Practice Address - Fax:302-733-4832
Is Sole Proprietor?:No
Enumeration Date:2016-06-23
Last Update Date:2024-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC5-0001081363A00000X
WAPA60805561363AS0400X
MDC08878363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant