Provider Demographics
NPI:1053395913
Name:BEFAY, TRACEY W (PA)
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:W
Last Name:BEFAY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:TRACEY
Other - Middle Name:M
Other - Last Name:WOLF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 22487
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2487
Mailing Address - Country:US
Mailing Address - Phone:920-445-7210
Mailing Address - Fax:
Practice Address - Street 1:1630 COMMANCHE AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54313-5753
Practice Address - Country:US
Practice Address - Phone:920-433-6000
Practice Address - Fax:920-430-4719
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI474363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1016871OtherNATIONAL COMMISSION ON CERTIFIED PHYSICIANS ASSISTANTS
WI474-023OtherLICENSE
WI474-023OtherLICENSE
WI080097289Medicare PIN