Provider Demographics
NPI:1154762706
Name:LARK, TRACEY (PAC)
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:
Last Name:LARK
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3811 OHARA ST
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15213-2593
Mailing Address - Country:US
Mailing Address - Phone:412-586-9330
Mailing Address - Fax:
Practice Address - Street 1:3811 OHARA ST
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15213-2593
Practice Address - Country:US
Practice Address - Phone:412-586-9330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-11
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA001024L363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant