Provider Demographics
NPI:1154892073
Name:JIANG, TRACY DAN
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:DAN
Last Name:JIANG
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 1:72 MAPLELEAF DR
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14221-2714
Mailing Address - Country:US
Mailing Address - Phone:713-447-7856
Mailing Address - Fax:
Practice Address - Street 1:2A RICHMOND AVE
Practice Address - Street 2:
Practice Address - City:BATAVIA
Practice Address - State:NY
Practice Address - Zip Code:14020-1408
Practice Address - Country:US
Practice Address - Phone:585-344-0628
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-17
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007882133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY133V00000XMedicaid