Provider Demographics
NPI:1952460057
Name:MARTIN, TRACY B (PA)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:B
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3500 TRINITY DR STE C3
Mailing Address - Street 2:
Mailing Address - City:LOS ALAMOS
Mailing Address - State:NM
Mailing Address - Zip Code:87544-2221
Mailing Address - Country:US
Mailing Address - Phone:505-500-8213
Mailing Address - Fax:505-391-8935
Practice Address - Street 1:2610 TRINITY DR STE 14
Practice Address - Street 2:
Practice Address - City:LOS ALAMOS
Practice Address - State:NM
Practice Address - Zip Code:87544-2362
Practice Address - Country:US
Practice Address - Phone:505-500-8213
Practice Address - Fax:505-451-0580
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NM99PA28207QA0505X
NM99-PA28363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000N1651Medicaid
10029201OtherLOVELACE
QMP000003399104OtherMOLINA
NM000N1651Medicaid