=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790982643
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RANDOLPH P BACA JR. MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/02/2007
-----------------------------------------------------
Last Update Date | 08/29/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1003 LUNA CIR NW
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87102-1973
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-504-5505
-----------------------------------------------------
Fax | 505-214-5614
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 95602
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87199
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-504-5505
-----------------------------------------------------
Fax | 505-214-5614
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | AG3361893-B416
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------