Provider Demographics
NPI:1942204763
Name:GORDON, TRACY A (MD)
Entity Type:Individual
Prefix:DR
First Name:TRACY
Middle Name:A
Last Name:GORDON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1720 LOUISIANA BLVD NE
Mailing Address - Street 2:STE 401
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-7020
Mailing Address - Country:US
Mailing Address - Phone:505-260-4300
Mailing Address - Fax:505-260-4338
Practice Address - Street 1:1205 S TELSHOR BLVD
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-4748
Practice Address - Country:US
Practice Address - Phone:505-260-4300
Practice Address - Fax:505-260-4338
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NM97-63207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMQ0054Medicaid
NMNM009V08OtherBLUE CROSS BLUE SHIELD
NMQ0054Medicaid