Healthcare Provider Details

I. General information

NPI: 1730181942
Provider Name (Legal Business Name): WILLIAM T BACON IV PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2005
Last Update Date: 03/06/2025
Certification Date: 03/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 HOSPITAL DR STE 500
SANTA FE NM
87505-4794
US

IV. Provider business mailing address

1650 HOSPITAL DR STE 500
SANTA FE NM
87505-4794
US

V. Phone/Fax

Practice location:
  • Phone: 505-670-1976
  • Fax: 505-983-7212
Mailing address:
  • Phone: 505-670-1976
  • Fax: 505-983-7212

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number2001-PA36
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: