Provider Demographics
NPI:1053526772
Name:REEVES, TRACY B (PA)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:B
Last Name:REEVES
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 NNPTC CIR
Mailing Address - Street 2:
Mailing Address - City:GOOSE CREEK
Mailing Address - State:SC
Mailing Address - Zip Code:29445-6314
Mailing Address - Country:US
Mailing Address - Phone:843-636-1765
Mailing Address - Fax:843-794-6036
Practice Address - Street 1:110 NNPTC CIR
Practice Address - Street 2:
Practice Address - City:GOOSE CREEK
Practice Address - State:SC
Practice Address - Zip Code:29445-6314
Practice Address - Country:US
Practice Address - Phone:843-794-6840
Practice Address - Fax:843-794-6036
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2024-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC648363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCP00846491OtherRR - MEDICARE#
SC0682PAMedicaid
SCP00846491OtherRR - MEDICARE#
SCAA36767006Medicare PIN