1922094853 NPI number — TRACY A EVANS PA-C

Table of content: TRACY A EVANS PA-C (NPI 1922094853)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922094853 NPI number — TRACY A EVANS PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EVANS
Provider First Name:
TRACY
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-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:
1922094853
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/16/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
725 RESERVOIR AVE
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
CRANSTON
Provider Business Mailing Address State Name:
RI
Provider Business Mailing Address Postal Code:
02910-4448
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
401-944-3800
Provider Business Mailing Address Fax Number:
401-944-1342

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2138 MENDON RD
Provider Second Line Business Practice Location Address:
SUITE 302
Provider Business Practice Location Address City Name:
CUMBERLAND
Provider Business Practice Location Address State Name:
RI
Provider Business Practice Location Address Postal Code:
02864-3834
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
401-334-1060
Provider Business Practice Location Address Fax Number:
401-334-1063
Provider Enumeration Date:
09/26/2005

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: 363AS0400X , with the licence number:  CPA00245 , registered in the state of RI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2036 . This is a "BC" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 408249 . This is a "BLUE CHIP" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 7008740 , issued by the state of ( RI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1922094853 . This is a "DURABLE" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".




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