Provider Demographics
NPI:1164930616
Name:BACON, KAELA (PA)
Entity Type:Individual
Prefix:
First Name:KAELA
Middle Name:
Last Name:BACON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38135 MARKET SQ
Mailing Address - Street 2:
Mailing Address - City:ZEPHYRHILLS
Mailing Address - State:FL
Mailing Address - Zip Code:33542-7505
Mailing Address - Country:US
Mailing Address - Phone:352-567-0188
Mailing Address - Fax:
Practice Address - Street 1:2352 BRUCE B DOWNS BLVD STE 101
Practice Address - Street 2:
Practice Address - City:WESLEY CHAPEL
Practice Address - State:FL
Practice Address - Zip Code:33544-9203
Practice Address - Country:US
Practice Address - Phone:813-929-3600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-18
Last Update Date:2020-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9110761363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant