Provider Demographics
NPI:1518687383
Name:BACON, LAUREN (PA-C)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:BACON
Suffix:
Gender:F
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 1:661 E ALTAMONTE DR STE 325
Mailing Address - Street 2:
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32701-5103
Mailing Address - Country:US
Mailing Address - Phone:407-303-4120
Mailing Address - Fax:407-303-4124
Practice Address - Street 1:601 E ALTAMONTE DR STE 325
Practice Address - Street 2:
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32701-4802
Practice Address - Country:US
Practice Address - Phone:407-303-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-31
Last Update Date:2022-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9116460363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant