Basic Information
| Provider Information | |||||||||
| NPI: | 1174874861 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ALLEN | ||||||||
| FirstName: | TRACIE | ||||||||
| MiddleName: | |||||||||
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| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KOEBCKE | ||||||||
| OtherFirstName: | TRACIE | ||||||||
| OtherMiddleName: | |||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 262 DANNY THOMAS PL # MS 515 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381053678 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9015953300 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 262 DANNY THOMAS PL | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 38105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9015953300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2012 | ||||||||
| LastUpdateDate: | 07/18/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 085004390 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 2417 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.