Provider Demographics
NPI:1174874861
Name:ALLEN, TRACIE (PA-C)
Entity type:Individual
Prefix:
First Name:TRACIE
Middle Name:
Last Name:ALLEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:TRACIE
Other - Middle Name:
Other - Last Name:KOEBCKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:262 DANNY THOMAS PL # MS 515
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38105-3678
Mailing Address - Country:US
Mailing Address - Phone:901-595-3300
Mailing Address - Fax:
Practice Address - Street 1:262 DANNY THOMAS PL
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38105
Practice Address - Country:US
Practice Address - Phone:901-595-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-21
Last Update Date:2018-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085004390363A00000X
TN2417363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant