Healthcare Provider Details

I. General information

NPI: 1952460057
Provider Name (Legal Business Name): TRACY B MARTIN PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2006
Last Update Date: 10/11/2022
Certification Date: 10/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2610 TRINITY DR STE 14
LOS ALAMOS NM
87544-2362
US

IV. Provider business mailing address

3500 TRINITY DR STE C3
LOS ALAMOS NM
87544-2221
US

V. Phone/Fax

Practice location:
  • Phone: 505-500-8213
  • Fax: 505-451-0580
Mailing address:
  • Phone: 505-500-8213
  • Fax: 505-391-8935

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number99PA28
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number99-PA28
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: