Provider Demographics
NPI:1891836045
Name:MORELAND, TRACI M (MPA-C)
Entity type:Individual
Prefix:MS
First Name:TRACI
Middle Name:M
Last Name:MORELAND
Suffix:
Gender:F
Credentials:MPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1455 HARRISON AVE NW
Mailing Address - Street 2:SUITE 105
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44708-2621
Mailing Address - Country:US
Mailing Address - Phone:330-453-9993
Mailing Address - Fax:330-453-9996
Practice Address - Street 1:1455 HARRISON AVE NW
Practice Address - Street 2:SUITE 105
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44708-2621
Practice Address - Country:US
Practice Address - Phone:330-453-9993
Practice Address - Fax:330-453-9996
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2008-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50-00-1745363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH4169790001Medicaid
OH4169790001Medicaid
OHMOPA25341Medicare PIN