Healthcare Provider Details

I. General information

NPI: 1194822122
Provider Name (Legal Business Name): MARK H BAYLISS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 03/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 HOSPITAL DR
RATON NM
87740-2002
US

IV. Provider business mailing address

190 HOSPITAL DR
RATON NM
87740-2002
US

V. Phone/Fax

Practice location:
  • Phone: 575-445-5563
  • Fax: 575-445-5566
Mailing address:
  • Phone: 575-445-5563
  • Fax: 575-445-5566

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA-3536
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: