Provider Demographics
NPI:1821024746
Name:HAZELTON, TRACY M (PA-C)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:M
Last Name:HAZELTON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1950
Mailing Address - Street 2:
Mailing Address - City:LAKEPORT
Mailing Address - State:CA
Mailing Address - Zip Code:95453-1950
Mailing Address - Country:US
Mailing Address - Phone:707-263-8382
Mailing Address - Fax:707-263-1909
Practice Address - Street 1:14440 OLYMPIC DRIVE
Practice Address - Street 2:
Practice Address - City:CLEARLAKE
Practice Address - State:CA
Practice Address - Zip Code:95422-8809
Practice Address - Country:US
Practice Address - Phone:707-263-8383
Practice Address - Fax:707-263-5019
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2025-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA13690363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PA136900Medicare ID - Type Unspecified