=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033167218
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LINDA BACO PAC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/04/2006
-----------------------------------------------------
Last Update Date | 05/19/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 22 WEST UNDERWOOD ST 4TH FLOOR
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32806
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-649-6878
-----------------------------------------------------
Fax | 407-843-7381
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 102 WEST PINELOCH AVENUE SUITE 23
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32806-6100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-481-7173
-----------------------------------------------------
Fax | 407-481-7190
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | PA9102870
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------