Provider Demographics
NPI:1427074087
Name:KWIAT, TRACEY (PAC)
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:
Last Name:KWIAT
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 1:1868 WILENE DR
Mailing Address - Street 2:
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45432-4022
Mailing Address - Country:US
Mailing Address - Phone:937-208-2088
Mailing Address - Fax:937-208-2898
Practice Address - Street 1:1868 WILENE DR
Practice Address - Street 2:
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45432-4022
Practice Address - Country:US
Practice Address - Phone:937-208-2088
Practice Address - Fax:937-208-2898
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50001904363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHPA19634Medicare ID - Type Unspecified
OHPA19633Medicare ID - Type Unspecified
OHPA19631Medicare ID - Type Unspecified
OHPA19632Medicare ID - Type Unspecified