Provider Demographics
NPI:1831310382
Name:BACEVICH, MARY E (NP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:BACEVICH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 CENTRAL AVE SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-4930
Mailing Address - Country:US
Mailing Address - Phone:505-841-1125
Mailing Address - Fax:505-841-1737
Practice Address - Street 1:1100 CENTRAL AVE SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-4930
Practice Address - Country:US
Practice Address - Phone:505-841-1125
Practice Address - Fax:505-841-1737
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209001262363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK11073Medicare ID - Type Unspecified
ILP69884Medicare UPIN