Provider Demographics
NPI:1194822122
Name:BAYLISS, MARK H (PA-C)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:H
Last Name:BAYLISS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:RATON
Mailing Address - State:NM
Mailing Address - Zip Code:87740-2002
Mailing Address - Country:US
Mailing Address - Phone:575-445-5563
Mailing Address - Fax:575-445-5566
Practice Address - Street 1:190 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:RATON
Practice Address - State:NM
Practice Address - Zip Code:87740-2002
Practice Address - Country:US
Practice Address - Phone:575-445-5563
Practice Address - Fax:575-445-5566
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2011-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA-3536363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMR94998Medicare UPIN