Provider Demographics
NPI:1992779052
Name:KORTRIGHT, TRACIE
Entity type:Individual
Prefix:
First Name:TRACIE
Middle Name:
Last Name:KORTRIGHT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:231 GRANITE RUN DR
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17601-6823
Mailing Address - Country:US
Mailing Address - Phone:717-560-4200
Mailing Address - Fax:717-560-4159
Practice Address - Street 1:170 N POINTE BLVD
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17601-4132
Practice Address - Country:US
Practice Address - Phone:717-299-4871
Practice Address - Fax:717-391-2494
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2020-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA003611L363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA970028712OtherMEDICARE-RAILROAD
PA054079OtherMEDICARE-DME
PA970028712OtherMEDICARE-RAILROAD
PA054079EKXMedicare PIN