Provider Demographics
NPI:1538205851
Name:CUMBERLAND, TRACY LYNNE (PA-C, PHD)
Entity type:Individual
Prefix:DR
First Name:TRACY
Middle Name:LYNNE
Last Name:CUMBERLAND
Suffix:
Gender:F
Credentials:PA-C, PHD
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:LYNNE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:14044 W CAMELBACK RD STE 118J
Mailing Address - Street 2:
Mailing Address - City:LITCHFIELD PARK
Mailing Address - State:AZ
Mailing Address - Zip Code:85340-9428
Mailing Address - Country:US
Mailing Address - Phone:623-547-2600
Mailing Address - Fax:623-547-1899
Practice Address - Street 1:5750 W THUNDERBIRD RD STE B200
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85306-4664
Practice Address - Country:US
Practice Address - Phone:602-375-1700
Practice Address - Fax:602-978-1225
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2022-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC01254363A00000X
AZ7357363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ469723Medicaid