Provider Demographics
NPI:1578808333
Name:BAUKOL, ANDREW WILLIAM (PA-C)
Entity Type:Individual
Prefix:MR
First Name:ANDREW
Middle Name:WILLIAM
Last Name:BAUKOL
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 1:1909 VISTA DR
Mailing Address - Street 2:
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82070-5599
Mailing Address - Country:US
Mailing Address - Phone:307-745-8851
Mailing Address - Fax:307-742-0961
Practice Address - Street 1:1909 VISTA DR
Practice Address - Street 2:
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82070-5599
Practice Address - Country:US
Practice Address - Phone:307-745-8851
Practice Address - Fax:307-742-0961
Is Sole Proprietor?:No
Enumeration Date:2012-12-05
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5322363A00000X
WYPT925363AS0400X, 363A00000X
IDPA-1379363AS0400X
SC363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSC07541223Medicare PIN