1184781973 NPI number — MS. TRACY ELLEN FEARNSIDE P.A.-C.

Table of content: MS. TRACY ELLEN FEARNSIDE P.A.-C. (NPI 1184781973)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184781973 NPI number — MS. TRACY ELLEN FEARNSIDE P.A.-C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FEARNSIDE
Provider First Name:
TRACY
Provider Middle Name:
ELLEN
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
P.A.-C.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1184781973
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PRIMARY CARE ASSOCIATE PROGRAM, STANFORD UNIVERSITY SCH
Provider Second Line Business Mailing Address:
1215 WELCH RD. , MODULAR G
Provider Business Mailing Address City Name:
PALO ALTO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94305-5408
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
650-736-7773
Provider Business Mailing Address Fax Number:
650-723-9692

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
680 W. TENNYSON RD.
Provider Second Line Business Practice Location Address:
SILVA CLINIC
Provider Business Practice Location Address City Name:
HAYWARD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94544
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
510-782-4470
Provider Business Practice Location Address Fax Number:
510-782-4756
Provider Enumeration Date:
01/02/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  PA 11284 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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