Provider Demographics
NPI:1366773061
Name:DEMARCO, TRACIE MARIE (FNP)
Entity type:Individual
Prefix:
First Name:TRACIE
Middle Name:MARIE
Last Name:DEMARCO
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:TRACIE
Other - Middle Name:MARIE
Other - Last Name:WALSH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:200 OCEANGATE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802-4317
Mailing Address - Country:US
Mailing Address - Phone:916-564-0521
Mailing Address - Fax:877-860-2907
Practice Address - Street 1:3946 NORWOOD AVE
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95838-3300
Practice Address - Country:US
Practice Address - Phone:916-564-0521
Practice Address - Fax:877-860-2907
Is Sole Proprietor?:No
Enumeration Date:2010-01-19
Last Update Date:2015-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19440363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP01453311-DV5277OtherRAILROAD MEDICARE
CAP01392649OtherRAILROAD MEDICARE-DS9933
CACA143579Medicare PIN
CACA133314-EFF 8/25/14Medicare PIN