Basic Information
| Provider Information | |||||||||
| NPI: | 1154744456 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WERTZ-TRACY | ||||||||
| FirstName: | MEGHAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DPT | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | TRACY | ||||||||
| OtherFirstName: | MEGHAN | ||||||||
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| OtherCredential: | DPT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 655 NORTHERN BLVD | ||||||||
| Address2: | |||||||||
| City: | SOUTH ABINGTON TOWNSHIP | ||||||||
| State: | PA | ||||||||
| PostalCode: | 184118740 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5708429323 | ||||||||
| FaxNumber: | 5708429362 | ||||||||
| Practice Location | |||||||||
| Address1: | 42 COMPLEX DR | ||||||||
| Address2: | |||||||||
| City: | WYALUSING | ||||||||
| State: | PA | ||||||||
| PostalCode: | 188537803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5707460504 | ||||||||
| FaxNumber: | 5707460470 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2014 | ||||||||
| LastUpdateDate: | 03/06/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT023258 | PA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1028968300001 | 05 | PA | MEDICAID |