MEDICARE: JON TODD BAUGHMAN PAC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA20020040	NM

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1275629339
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JON TODD BAUGHMAN PAC

Provider Business Mailing Address
First Line	:	PO BOX 4363
Second Line	:	870 HERON DRIVE
City	:	PAGE
State	:	AZ
Zip	:	86040-4363
Country	:	US
Telephone Number	:	928-660-1337
Fax Number	:

Provider Business Practice Location Address
First Line	:	11495 CALLISON STREET
Second Line	:	LIFE HOUSE COMMUNITY HEALTH CENTER
City	:	SUTTON
State	:	AK
Zip	:	99674-0000
Country	:	US
Telephone Number	:	907-631-7665
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/05/2006
Last Update Date	:	03/03/2016

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