Provider Demographics
NPI:1104072040
Name:GROSSMAN, TRACI LYNN (PA-C)
Entity type:Individual
Prefix:MRS
First Name:TRACI
Middle Name:LYNN
Last Name:GROSSMAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3602 ELMHURST AVE
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48073-2332
Mailing Address - Country:US
Mailing Address - Phone:989-415-8652
Mailing Address - Fax:
Practice Address - Street 1:2000 GREEN RD
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48105-1598
Practice Address - Country:US
Practice Address - Phone:734-995-2913
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-12
Last Update Date:2012-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI5601005369363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIC37626078Medicare PIN