Provider Demographics
NPI:1497981229
Name:BASLER, TRACY (LMT#5612)
Entity Type:Individual
Prefix:MR
First Name:TRACY
Middle Name:
Last Name:BASLER
Suffix:
Gender:M
Credentials:LMT#5612
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10348 FLAGSTAFF DR. NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87114
Mailing Address - Country:US
Mailing Address - Phone:505-307-9964
Mailing Address - Fax:
Practice Address - Street 1:10348 FLAGSTAFF DR NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87114-3544
Practice Address - Country:US
Practice Address - Phone:505-307-9964
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-08
Last Update Date:2009-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM5612174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist