Provider Demographics
NPI:1912143835
Name:GARDNER, TRACIE PHAM (MD)
Entity type:Individual
Prefix:DR
First Name:TRACIE
Middle Name:PHAM
Last Name:GARDNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 WASHINGTON ST
Mailing Address - Street 2:BOX #802
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02111-1552
Mailing Address - Country:US
Mailing Address - Phone:617-636-1152
Mailing Address - Fax:
Practice Address - Street 1:800 WASHINGTON ST
Practice Address - Street 2:BOX #802
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02111-1552
Practice Address - Country:US
Practice Address - Phone:617-636-1152
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-23
Last Update Date:2012-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZR71171207ZP0102X
CAA110863207ZN0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZN0500XAllopathic & Osteopathic PhysiciansPathologyNeuropathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
R71171OtherTRAINING PERMIT
CAA110863OtherCALIFORNIA MEDICAL LICENSE