Basic Information
| Provider Information | |||||||||
| NPI: | 1205901469 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FOX NELSON | ||||||||
| FirstName: | TRACY | ||||||||
| MiddleName: | N | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | P.A. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FOX | ||||||||
| OtherFirstName: | TRACY | ||||||||
| OtherMiddleName: | N | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 30532 | ||||||||
| Address2: | |||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325031532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8509163700 | ||||||||
| FaxNumber: | 8509163710 | ||||||||
| Practice Location | |||||||||
| Address1: | 1040 GULF BREEZE PKWY | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | GULF BREEZE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325617809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8509163700 | ||||||||
| FaxNumber: | 8509163710 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/22/2006 | ||||||||
| LastUpdateDate: | 11/29/2011 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA9102098 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | CL2119 | 01 | FL | MEDICARE RAILROAD | OTHER | 59193887 | 01 | AL | BCBS ALABAMA - GBO | OTHER | Y01C8 | 01 | FL | BLUE CROSS BLUE SHIELD | OTHER | 115029 | 05 | AL | MEDICAID | P00397348 | 01 | FL | MEDICARE RAILROAD | OTHER | 000215800 | 05 | FL | MEDICAID | 592-09448 | 01 | AL | BLUE CROSS BLUE SHIELD | OTHER | 59197534 | 01 | AL | BCBS ALABAMA | OTHER | 9147144 | 01 | AETNA PIN | OTHER | P00869427 | 01 | MEDICARE RAILROAD | OTHER |