Provider Demographics
NPI:1881905263
Name:TRACEY, EMILY J (PA)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:J
Last Name:TRACEY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:R
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 9007
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22906-9007
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:57 BEAM LN STE 202
Practice Address - Street 2:
Practice Address - City:FISHERSVILLE
Practice Address - State:VA
Practice Address - Zip Code:22939-2350
Practice Address - Country:US
Practice Address - Phone:540-932-0980
Practice Address - Fax:540-932-0979
Is Sole Proprietor?:No
Enumeration Date:2010-06-30
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110009118208000000X, 363A00000X
WI2623-23363A00000X
MN10955363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No208000000XAllopathic & Osteopathic PhysiciansPediatrics