Provider Demographics
NPI:1053524330
Name:HIXSON, TRACEY (R)
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:
Last Name:HIXSON
Suffix:
Gender:F
Credentials:R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 BEACHWOOD LN
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32413-2792
Mailing Address - Country:US
Mailing Address - Phone:850-719-2253
Mailing Address - Fax:
Practice Address - Street 1:1827 HARRISON AVE
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-7605
Practice Address - Country:US
Practice Address - Phone:850-785-4344
Practice Address - Fax:850-785-9395
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL290008247100000X
239771247100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic Technologist