Provider Demographics
NPI:1366947533
Name:MIX, TRACY ANNE (PA-C)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:ANNE
Last Name:MIX
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27664 WESTCHESTER PKWY APT A
Mailing Address - Street 2:
Mailing Address - City:WESTLAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44145-1216
Mailing Address - Country:US
Mailing Address - Phone:937-681-0383
Mailing Address - Fax:
Practice Address - Street 1:33300 CLEVELAND CLINIC BLVD
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:OH
Practice Address - Zip Code:44011-1172
Practice Address - Country:US
Practice Address - Phone:440-371-8395
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-28
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601008591363A00000X
NY025684363A00000X
OH50.005845RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant