Provider Demographics
NPI:1902080682
Name:HOLDEN, TRACIE (PA-C)
Entity Type:Individual
Prefix:
First Name:TRACIE
Middle Name:
Last Name:HOLDEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:TRACIE
Other - Middle Name:
Other - Last Name:VAN HOECK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3901 BEAUBIEN ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2119
Mailing Address - Country:US
Mailing Address - Phone:313-993-4490
Mailing Address - Fax:313-745-7222
Practice Address - Street 1:3901 BEAUBIEN ST
Practice Address - Street 2:2ND FLOOR NEUROSURGERY CLINIC
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2119
Practice Address - Country:US
Practice Address - Phone:313-993-4490
Practice Address - Fax:313-745-7222
Is Sole Proprietor?:No
Enumeration Date:2007-12-18
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005115363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant