Provider Demographics
NPI:1053381319
Name:SMITH, TRACIE D (NP)
Entity type:Individual
Prefix:
First Name:TRACIE
Middle Name:D
Last Name:SMITH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:TRACIE
Other - Middle Name:DENISE
Other - Last Name:EVATT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1 INDEPENDENCE PT
Mailing Address - Street 2:SUITE 212
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4545
Mailing Address - Country:US
Mailing Address - Phone:864-797-6044
Mailing Address - Fax:
Practice Address - Street 1:100 OMNI DR
Practice Address - Street 2:SUITE B
Practice Address - City:SENECA
Practice Address - State:SC
Practice Address - Zip Code:29672-9448
Practice Address - Country:US
Practice Address - Phone:864-482-2350
Practice Address - Fax:864-482-2355
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2024-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCAPN2677363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP4697Medicaid
SC8768Medicare PIN
SCQ49160Medicare UPIN
SCAA10328303Medicare ID - Type Unspecified