Provider Demographics
NPI:1386658094
Name:C DE BACA, PATRICK J (MD)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:J
Last Name:C DE BACA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 N 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:NM
Mailing Address - Zip Code:88415-3300
Mailing Address - Country:US
Mailing Address - Phone:575-374-2273
Mailing Address - Fax:575-374-2498
Practice Address - Street 1:315 N 3RD AVE
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:NM
Practice Address - Zip Code:88415-3300
Practice Address - Country:US
Practice Address - Phone:575-374-2273
Practice Address - Fax:575-374-2498
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2010-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301044788208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4879970Medicaid
MI4879970Medicaid