Provider Demographics
NPI:1386706018
Name:MATHENA, TRACY LEE (MD)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:LEE
Last Name:MATHENA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:685 LORETTO DR
Mailing Address - Street 2:
Mailing Address - City:WYTHEVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24382-2085
Mailing Address - Country:US
Mailing Address - Phone:272-228-2216
Mailing Address - Fax:
Practice Address - Street 1:600 W RIDGE RD
Practice Address - Street 2:WYTHE COUNTY COMMUNITY HOSPITAL
Practice Address - City:WYTHEVILLE
Practice Address - State:VA
Practice Address - Zip Code:24382-1044
Practice Address - Country:US
Practice Address - Phone:276-228-1775
Practice Address - Fax:276-228-1776
Is Sole Proprietor?:No
Enumeration Date:2006-12-16
Last Update Date:2009-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101240789207Q00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100049800Medicaid
KY7100049800Medicaid
VAP00662728Medicare PIN