Basic Information
| Provider Information | |||||||||
| NPI: | 1417984410 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LIM | ||||||||
| FirstName: | TRACY | ||||||||
| MiddleName: | DANG | ||||||||
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| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 260 E HOLT AVE | ||||||||
| Address2: | |||||||||
| City: | POMONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917675426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9096298088 | ||||||||
| FaxNumber: | 9096298755 | ||||||||
| Practice Location | |||||||||
| Address1: | 1420 S CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | GLENDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 912042508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8185022344 | ||||||||
| FaxNumber: | 8185024501 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2006 | ||||||||
| LastUpdateDate: | 09/17/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA18103 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | PA18103 | 05 | CA | MEDICAID |