Provider Demographics
NPI:1235135427
Name:BASSO, TRACY LEE (DPM)
Entity Type:Individual
Prefix:DR
First Name:TRACY
Middle Name:LEE
Last Name:BASSO
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:635 ANDERSON RD
Mailing Address - Street 2:STE 19
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95616-3505
Mailing Address - Country:US
Mailing Address - Phone:530-758-1810
Mailing Address - Fax:530-758-1896
Practice Address - Street 1:635 ANDERSON RD
Practice Address - Street 2:STE 19
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95616-3505
Practice Address - Country:US
Practice Address - Phone:530-758-1810
Practice Address - Fax:530-758-1896
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-22
Last Update Date:2022-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE36260213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E36260Medicaid
CA3606880001Medicare NSC
CAT81920Medicare UPIN
CA000E6260Medicare PIN
CA3606880002Medicare NSC