Provider Demographics
NPI:1972835973
Name:CONNELL, TRACEY RENEE (PA)
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:RENEE
Last Name:CONNELL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:TRACEY
Other - Middle Name:RENEE
Other - Last Name:LIM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:126 GLASSON WAY
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-5706
Mailing Address - Country:US
Mailing Address - Phone:530-272-2303
Mailing Address - Fax:530-272-9648
Practice Address - Street 1:126 GLASSON WAY
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-5706
Practice Address - Country:US
Practice Address - Phone:530-272-2303
Practice Address - Fax:530-272-9648
Is Sole Proprietor?:No
Enumeration Date:2010-02-02
Last Update Date:2024-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA61681363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO020852OtherKAISER COMMERCIAL NUMBER
CO37355031Medicaid
CO020852OtherKAISER COMMERCIAL NUMBER