Provider Demographics
NPI:1164592275
Name:CLONINGER, TRACEY S (PA-C)
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:S
Last Name:CLONINGER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 23329
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10087-3329
Mailing Address - Country:US
Mailing Address - Phone:919-782-2152
Mailing Address - Fax:919-782-7929
Practice Address - Street 1:4201 LAKE BOONE TRL
Practice Address - Street 2:SUITE 200
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-7511
Practice Address - Country:US
Practice Address - Phone:919-782-2152
Practice Address - Fax:919-782-7929
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2025-11-06
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NC103242363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP70380Medicare UPIN
2756077AMedicare PIN