Provider Demographics
NPI:1033167218
Name:BACO, LINDA (PAC)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:
Last Name:BACO
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 WEST PINELOCH AVENUE
Mailing Address - Street 2:SUITE 23
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-6100
Mailing Address - Country:US
Mailing Address - Phone:407-481-7173
Mailing Address - Fax:407-481-7190
Practice Address - Street 1:22 WEST UNDERWOOD ST
Practice Address - Street 2:4TH FLOOR
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806
Practice Address - Country:US
Practice Address - Phone:407-649-6878
Practice Address - Fax:407-843-7381
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-04
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9102870363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL300725OtherAVMED
FL292355600Medicaid
U7180AOtherMEDICARE
FL292355600Medicaid
U7180AOtherMEDICARE