Provider Demographics
NPI:1275629339
Name:BAUGHMAN, JON TODD (PAC)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:TODD
Last Name:BAUGHMAN
Suffix:
Gender:M
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:PO BOX 4363
Mailing Address - Street 2:870 HERON DRIVE
Mailing Address - City:PAGE
Mailing Address - State:AZ
Mailing Address - Zip Code:86040-4363
Mailing Address - Country:US
Mailing Address - Phone:928-660-1337
Mailing Address - Fax:
Practice Address - Street 1:11495 CALLISON STREET
Practice Address - Street 2:LIFE HOUSE COMMUNITY HEALTH CENTER
Practice Address - City:SUTTON
Practice Address - State:AK
Practice Address - Zip Code:99674-0000
Practice Address - Country:US
Practice Address - Phone:907-631-7665
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA20020040363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ442226Medicaid
AZ442226Medicaid