1538205851 NPI number — DR. TRACY LYNNE CUMBERLAND PA-C, PHD

Table of content: DR. TRACY LYNNE CUMBERLAND PA-C, PHD (NPI 1538205851)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538205851 NPI number — DR. TRACY LYNNE CUMBERLAND PA-C, PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CUMBERLAND
Provider First Name:
TRACY
Provider Middle Name:
LYNNE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PA-C, PHD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SMITH
Provider Other First Name:
TRACY
Provider Other Middle Name:
LYNNE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1538205851
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/27/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14044 W CAMELBACK RD STE 118J
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LITCHFIELD PARK
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85340-9428
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
623-547-2600
Provider Business Mailing Address Fax Number:
623-547-1899

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5750 W THUNDERBIRD RD STE B200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GLENDALE
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85306-4664
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-375-1700
Provider Business Practice Location Address Fax Number:
602-978-1225
Provider Enumeration Date:
01/30/2007

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:  C01254 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: 7357 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 469723 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".