Provider Demographics
NPI:1699734335
Name:BARETELA, TRACIE (PA)
Entity type:Individual
Prefix:
First Name:TRACIE
Middle Name:
Last Name:BARETELA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5349 W CANARY GRASS WAY
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84009-1399
Mailing Address - Country:US
Mailing Address - Phone:360-689-6397
Mailing Address - Fax:
Practice Address - Street 1:HC 63 BOX 9000
Practice Address - Street 2:
Practice Address - City:DILKON
Practice Address - State:AZ
Practice Address - Zip Code:86047-9477
Practice Address - Country:US
Practice Address - Phone:928-657-1000
Practice Address - Fax:928-289-6229
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2024-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10005007207P00000X, 363A00000X
AZ9887363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8451411Medicaid
WAP26297Medicare UPIN
UTP26297Medicare UPIN
UT005786121Medicare PIN
WA8451411Medicaid
WA8864098Medicare PIN
UT005568352Medicare PIN
UT005567141Medicare PIN
UT005568552Medicare PIN