Provider Demographics
NPI:1932285970
Name:BACON, PAUL (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:
Last Name:BACON
Suffix:
Gender:M
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:903 EAST LENNON STREET
Mailing Address - Street 2:SUITE 101
Mailing Address - City:EMORY
Mailing Address - State:TX
Mailing Address - Zip Code:75440
Mailing Address - Country:US
Mailing Address - Phone:903-474-9436
Mailing Address - Fax:903-473-3170
Practice Address - Street 1:903 EAST LENNON STREET
Practice Address - Street 2:SUITE 101
Practice Address - City:EMORY
Practice Address - State:TX
Practice Address - Zip Code:75440
Practice Address - Country:US
Practice Address - Phone:903-474-9436
Practice Address - Fax:903-473-3170
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-31
Last Update Date:2014-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1124006225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1124006OtherLICENSE
TX1124006OtherLICENSE