Provider Demographics
NPI:1548375934
Name:PRIDE, TRACY LEE (PA)
Entity type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:LEE
Last Name:PRIDE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 13008
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48901-3008
Mailing Address - Country:US
Mailing Address - Phone:517-364-9650
Mailing Address - Fax:517-364-9605
Practice Address - Street 1:1140 E MICHIGAN AVE STE 400
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912-1806
Practice Address - Country:US
Practice Address - Phone:517-364-9650
Practice Address - Fax:517-364-9605
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2019-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004110363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P27070017Medicare PIN