Basic Information
| Provider Information | |||||||||
| NPI: | 1609109024 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | TRACY | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LAZUR | ||||||||
| OtherFirstName: | TRACY | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 260 CALLE CAMPESINO | ||||||||
| Address2: | |||||||||
| City: | SAN CLEMENTE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926724553 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9493661053 | ||||||||
| FaxNumber: | 9495447880 | ||||||||
| Practice Location | |||||||||
| Address1: | 4190 CITY AVE | ||||||||
| Address2: | SUITE 528 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191311626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8664538800 | ||||||||
| FaxNumber: | 8447347689 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2009 | ||||||||
| LastUpdateDate: | 09/14/2015 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | MA054091 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AM0700X | PA21436 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.