Provider Demographics
NPI:1699429571
Name:TRACY, JAMIE LYNN (PA-C)
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:LYNN
Last Name:TRACY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:506 1ST AVE SE
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:SD
Mailing Address - Zip Code:57201-4499
Mailing Address - Country:US
Mailing Address - Phone:605-886-8482
Mailing Address - Fax:605-884-4300
Practice Address - Street 1:506 1ST AVE SE
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:SD
Practice Address - Zip Code:57201-4499
Practice Address - Country:US
Practice Address - Phone:605-886-8482
Practice Address - Fax:605-884-4300
Is Sole Proprietor?:No
Enumeration Date:2022-02-09
Last Update Date:2022-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1361363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant