Provider Demographics
NPI:1760026504
Name:HAWSE, TRACY LYNN (PA LLC)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:LYNN
Last Name:HAWSE
Suffix:
Gender:F
Credentials:PA LLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 S AUBURN ST
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-6576
Mailing Address - Country:US
Mailing Address - Phone:530-613-1284
Mailing Address - Fax:
Practice Address - Street 1:150 S AUBURN ST
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-6576
Practice Address - Country:US
Practice Address - Phone:530-613-1284
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-05
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95013954363LA2200X
FL11004875363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health