Provider Demographics
NPI:1831842095
Name:PETRILLI, TRACY LETICIA (PA-C)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:LETICIA
Last Name:PETRILLI
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 1:618 ELWOOD DRIVE
Mailing Address - Street 2:
Mailing Address - City:DUNCAN
Mailing Address - State:SC
Mailing Address - Zip Code:29334
Mailing Address - Country:US
Mailing Address - Phone:407-257-6988
Mailing Address - Fax:
Practice Address - Street 1:218 E BLACKSTOCK RD
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29301-2607
Practice Address - Country:US
Practice Address - Phone:864-576-8646
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-28
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4263363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant