Basic Information
| Provider Information | |||||||||
| NPI: | 1649512542 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARLSON | ||||||||
| FirstName: | TRACY | ||||||||
| MiddleName: | MARSH | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CARLSON | ||||||||
| OtherFirstName: | TRACY | ||||||||
| OtherMiddleName: | MICHELLE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 801 ENCINO PL NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871022612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052721312 | ||||||||
| FaxNumber: | 5052722240 | ||||||||
| Practice Location | |||||||||
| Address1: | 801 ENCINO PL NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871022612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052721312 | ||||||||
| FaxNumber: | 5052722240 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2013 | ||||||||
| LastUpdateDate: | 10/04/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | RS2013-0347 | NM | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207R00000X | MD2016-0616 | NM | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.