Basic Information
| Provider Information | |||||||||
| NPI: | 1922094853 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EVANS | ||||||||
| FirstName: | TRACY | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 725 RESERVOIR AVE | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | CRANSTON | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029104448 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4019443800 | ||||||||
| FaxNumber: | 4019441342 | ||||||||
| Practice Location | |||||||||
| Address1: | 2138 MENDON RD | ||||||||
| Address2: | SUITE 302 | ||||||||
| City: | CUMBERLAND | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028643834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4013341060 | ||||||||
| FaxNumber: | 4013341063 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2005 | ||||||||
| LastUpdateDate: | 05/16/2016 | ||||||||
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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 | 363AS0400X | CPA00245 | RI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 2036 | 01 | RI | BC | OTHER | 408249 | 01 | RI | BLUE CHIP | OTHER | 7008740 | 05 | RI | MEDICAID | 1922094853 | 01 | RI | DURABLE | OTHER |