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Individual
TRACEY ELIZABETH WILEY
Active
Individual
TRACEY ELIZABETH WILEY
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
CRNP
Taxonomy
Speciality
Code
Description
License number
State
363L00000X
Nurse Practitioner
Primary
TP005855B
PA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1007307260034
MEDICAID GROUP #
PA
05
—
102556669
—
PA
05
—
102556669 0001
—
PA
01
—
25-1716306
INTERGROUP
PA
01
—
867633
MEDICARE GROUP #
PA
01
—
TP005855B
LICENSE
PA
Enumeration date
03/24/2006
Last updated
04/29/2020
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