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General NPI Number Information
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NPI Number | 1093496069
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Entity Type | Individual
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Provider Name | IAN LLOYD RUIZ BACCAY RN
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Gender | Male
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Dates
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Enumeration Date | 07/31/2023
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Last Update Date | 06/12/2025
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Provider Practice Location Address
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Address Line | 5263 S HIGHWAY 95 , FORT MOHAVE, AZ 86426
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City | FORT MOHAVE
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State | AZ
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Zip | 86426-9223
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Country | US
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Telephone | 928-704-6400
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Fax |
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Provider Business Mailing Address
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Address Line | 4425 S BERNARD PL
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City | FORT MOHAVE
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State | AZ
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Zip | 86426-5388
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Country | US
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Telephone | 928-299-1268
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 100460
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License Number State | GU
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Taxonomy #2
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | 295726
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License Number State | AZ
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