Provider Demographics
NPI:1477866739
Name:BACON, PATRICK NEPHI (MD)
Entity Type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:NEPHI
Last Name:BACON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1304 FAWCETT AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98402-1911
Mailing Address - Country:US
Mailing Address - Phone:253-761-4200
Mailing Address - Fax:253-383-3553
Practice Address - Street 1:1304 FAWCETT AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402-1911
Practice Address - Country:US
Practice Address - Phone:253-761-4200
Practice Address - Fax:253-761-4201
Is Sole Proprietor?:No
Enumeration Date:2010-07-15
Last Update Date:2016-10-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAMD606402172085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2057248Medicaid