Provider Demographics
NPI:1659747681
Name:BRADFIELD, TRACY LANE (CNP)
Entity Type:Individual
Prefix:
First Name:TRACY LANE
Middle Name:
Last Name:BRADFIELD
Suffix:
Gender:M
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6704 BROADWAY BLVD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87107-5911
Mailing Address - Country:US
Mailing Address - Phone:505-453-0958
Mailing Address - Fax:
Practice Address - Street 1:5800 MCLEOD RD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-2454
Practice Address - Country:US
Practice Address - Phone:505-453-0958
Practice Address - Fax:505-422-8612
Is Sole Proprietor?:No
Enumeration Date:2015-08-13
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCNP-02695363LF0000X
NMCNP02695363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM50575716Medicaid