MEDICARE: KELLY BACON

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	367H00000X	Anesthesiologist Assistant	R0071221	OK
2	367500000X	Certified Registered Nurse Anesthetist	R0071221	OK

General Provider Information

NPI Number	:	1700844313
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY BACON

Provider Business Mailing Address
First Line	:	PO BOX 1547
Second Line	:
City	:	SEDALIA
State	:	MO
Zip	:	65302-1547
Country	:	US
Telephone Number	:	660-826-5960
Fax Number	:

Provider Business Practice Location Address
First Line	:	1301 E LINCOLN RD
Second Line	:
City	:	IDABEL
State	:	OK
Zip	:	74745-7300
Country	:	US
Telephone Number	:	580-286-7623
Fax Number	:

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

Provider Enumeration Date	:	05/03/2006
Last Update Date	:	10/26/2021

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Directions to “ KELLY BACON ” Practice Location

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