Provider Demographics
NPI:1801863410
Name:BACA, PHILIP MARTIN (PT)
Entity Type:Individual
Prefix:MR
First Name:PHILIP
Middle Name:MARTIN
Last Name:BACA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8100 M4 WYOMING BLVD. NE
Mailing Address - Street 2:#261
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87113-1956
Mailing Address - Country:US
Mailing Address - Phone:505-797-5505
Mailing Address - Fax:505-797-5510
Practice Address - Street 1:7424 HOLLY AVE. NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87113
Practice Address - Country:US
Practice Address - Phone:505-797-5505
Practice Address - Fax:505-797-5510
Is Sole Proprietor?:No
Enumeration Date:2006-03-02
Last Update Date:2013-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist