MEDICARE: DR. TRACY LYNN CONRAD DOM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171100000X	Acupuncturist	549	NM

General Provider Information

NPI Number	:	1578139150
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TRACY LYNN CONRAD DOM

Provider Business Mailing Address
First Line	:	644 PASEO DE PERALTA
Second Line	:
City	:	SANTA FE
State	:	NM
Zip	:	87501-1955
Country	:	US
Telephone Number	:	505-984-8830
Fax Number	:	505-982-1225

Provider Business Practice Location Address
First Line	:	644 PASEO DE PERALTA
Second Line	:
City	:	SANTA FE
State	:	NM
Zip	:	87501-1955
Country	:	US
Telephone Number	:	505-984-8830
Fax Number	:	505-982-1225

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/03/2021
Last Update Date	:	06/03/2021

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