Provider Demographics
NPI:1962716183
Name:SEBASTIAN, TRACY MEJIA (PA-C)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:MEJIA
Last Name:SEBASTIAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:RITUALO
Other - Last Name:MEJIA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1934 CORTE MARAVILLA
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91914-4627
Mailing Address - Country:US
Mailing Address - Phone:619-962-5508
Mailing Address - Fax:
Practice Address - Street 1:6645 ALVARADO RD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-5208
Practice Address - Country:US
Practice Address - Phone:858-810-0387
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-29
Last Update Date:2014-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA21043363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical