Provider Demographics
NPI:1801815691
Name:BACON, NICKI A (MD)
Entity Type:Individual
Prefix:DR
First Name:NICKI
Middle Name:A
Last Name:BACON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:3555 LUTHERAN PARKWAY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:WHEAT RIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80033-6018
Mailing Address - Country:US
Mailing Address - Phone:720-284-3700
Mailing Address - Fax:303-467-0525
Practice Address - Street 1:3555 LUTHERAN PARKWAY
Practice Address - Street 2:SUITE 200
Practice Address - City:WHEAT RIDGE
Practice Address - State:CO
Practice Address - Zip Code:80033-6018
Practice Address - Country:US
Practice Address - Phone:720-284-3700
Practice Address - Fax:303-467-0525
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2012-05-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CO36690208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO17206359Medicaid
CO17206359Medicaid