Provider Demographics
NPI:1831557826
Name:FISH, TRACEY (PAC)
Entity type:Individual
Prefix:MRS
First Name:TRACEY
Middle Name:
Last Name:FISH
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3205 SOUTH BLVD
Mailing Address - Street 2:
Mailing Address - City:AUBURN HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48326-3635
Mailing Address - Country:US
Mailing Address - Phone:248-293-0070
Mailing Address - Fax:248-293-0089
Practice Address - Street 1:3205 SOUTH BLVD
Practice Address - Street 2:
Practice Address - City:AUBURN HILLS
Practice Address - State:MI
Practice Address - Zip Code:48326-3635
Practice Address - Country:US
Practice Address - Phone:248-293-0070
Practice Address - Fax:248-293-0089
Is Sole Proprietor?:No
Enumeration Date:2016-02-04
Last Update Date:2016-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601002697363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant