Provider Demographics
NPI:1801930169
Name:LEONARD, TRACY LYNN (PA-C)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:LYNN
Last Name:LEONARD
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 1:1300 SENTARA PARK # 3
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23464-5884
Mailing Address - Country:US
Mailing Address - Phone:757-252-3050
Mailing Address - Fax:
Practice Address - Street 1:1300 SENTARA PARK # 3
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23464-5884
Practice Address - Country:US
Practice Address - Phone:757-252-3050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-19
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110002438363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0110002438OtherSTATE LICENSE
VA541870680OtherORGANIZATOIN TAX ID
VA541398620OtherORGANIZATION TAX ID