Basic Information
| Provider Information | |||||||||
| NPI: | 1659643385 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WOOD | ||||||||
| FirstName: | TRACI | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 127 S. 500 E | ||||||||
| Address2: | SUITE 600 | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841021971 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015876336 | ||||||||
| FaxNumber: | 8017158228 | ||||||||
| Practice Location | |||||||||
| Address1: | 196 E 2000 N | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | TOOELE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840749335 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4358827644 | ||||||||
| FaxNumber: | 4358822284 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2012 | ||||||||
| LastUpdateDate: | 12/20/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 8187126-1206 | UT | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | 8187126-1206 | UT | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.