Basic Information
| Provider Information | |||||||||
| NPI: | 1801930169 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEONARD | ||||||||
| FirstName: | TRACY | ||||||||
| MiddleName: | L | ||||||||
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| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1380 TUSCANY DR | ||||||||
| Address2: | |||||||||
| City: | VIRGINIA BEACH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234567751 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7573019200 | ||||||||
| FaxNumber: | 7573019214 | ||||||||
| Practice Location | |||||||||
| Address1: | 1380 TUSCANY DR | ||||||||
| Address2: | |||||||||
| City: | VIRGINIA BEACH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234567751 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7573019200 | ||||||||
| FaxNumber: | 7573019214 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/19/2007 | ||||||||
| LastUpdateDate: | 07/24/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 0110002438 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 541870680 | 01 | VA | ORGANIZATOIN TAX ID | OTHER | 541398620 | 01 | VA | ORGANIZATION TAX ID | OTHER | 0110002438 | 01 | VA | STATE LICENSE | OTHER |