Provider Demographics
NPI:1871575324
Name:CREEL, TRACY M (PA-C)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:M
Last Name:CREEL
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 1:411 WEBSTER ST
Mailing Address - Street 2:
Mailing Address - City:WILDWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:34785-4036
Mailing Address - Country:US
Mailing Address - Phone:352-748-6689
Mailing Address - Fax:352-748-6381
Practice Address - Street 1:411 WEBSTER ST
Practice Address - Street 2:
Practice Address - City:WILDWOOD
Practice Address - State:FL
Practice Address - Zip Code:34785-4036
Practice Address - Country:US
Practice Address - Phone:352-748-6689
Practice Address - Fax:352-748-6381
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2011-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPA064363AM0700X
FLPA9103034363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001311700Medicaid
MS03729301Medicaid
FLY0139OtherBLUECROSS/BLUESHIELD
FLY0139OtherBLUECROSS/BLUESHIELD
Q45984Medicare UPIN