Healthcare Provider Details

I. General information

NPI: 1679654909
Provider Name (Legal Business Name): THOMAS LAVERNE BACHINSKI PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 08/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 KEN PRATT BLVD SUITE 104
LONGMONT CO
80501-6567
US

IV. Provider business mailing address

5450 WESTERN AVE SUITE B
BOULDER CO
80301-2709
US

V. Phone/Fax

Practice location:
  • Phone: 303-415-4157
  • Fax: 303-776-3102
Mailing address:
  • Phone: 303-415-4770
  • Fax: 303-415-4769

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.0000246
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA.0000246
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: