Basic Information
| Provider Information | |||||||||
| NPI: | 1174055784 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FAN | ||||||||
| FirstName: | TRACEY | ||||||||
| MiddleName: | H | ||||||||
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| Credential: | D.O | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20 ENGLEWOOD AVE APT 104 | ||||||||
| Address2: | |||||||||
| City: | BROOKLINE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024452072 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 55 FRUIT ST # 721J | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021142696 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6177262000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2017 | ||||||||
| LastUpdateDate: | 02/28/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 287765 | MA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | SA6390894 | 01 | MA | DRIVER LICENSE | OTHER |