Provider Demographics
NPI:1063785962
Name:BURKE, TRACY FOSSAS
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:FOSSAS
Last Name:BURKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5471 CHAMBLEE DUNWOODY RD
Mailing Address - Street 2:
Mailing Address - City:DUNWOODY
Mailing Address - State:GA
Mailing Address - Zip Code:30338-4114
Mailing Address - Country:US
Mailing Address - Phone:770-481-0889
Mailing Address - Fax:
Practice Address - Street 1:5471 CHAMBLEE DUNWOODY RD
Practice Address - Street 2:
Practice Address - City:DUNWOODY
Practice Address - State:GA
Practice Address - Zip Code:30338-4114
Practice Address - Country:US
Practice Address - Phone:770-481-0889
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-23
Last Update Date:2012-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA006353363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical