Provider Demographics
NPI:1215137807
Name:MOISTER, TRACY VAN ELLS (PA-C)
Entity type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:VAN ELLS
Last Name:MOISTER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:TRACY
Other - Middle Name:KATHERINE
Other - Last Name:VAN ELLS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:105 HALTON VILLAGE CIR
Mailing Address - Street 2:STE A
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607-6832
Mailing Address - Country:US
Mailing Address - Phone:864-234-1433
Mailing Address - Fax:864-286-1462
Practice Address - Street 1:105 HALTON VILLAGE CIR STE A
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-6832
Practice Address - Country:US
Practice Address - Phone:864-234-1433
Practice Address - Fax:864-286-1462
Is Sole Proprietor?:No
Enumeration Date:2007-07-20
Last Update Date:2019-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1977363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant