Provider Demographics
NPI:1972530053
Name:BACON, MARK ROBERT (PA-C)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:ROBERT
Last Name:BACON
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 1:748 MILAN CT
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73034-6897
Mailing Address - Country:US
Mailing Address - Phone:405-330-4946
Mailing Address - Fax:
Practice Address - Street 1:72ND MEDICAL GROUP
Practice Address - Street 2:5700 ARNOLD ST
Practice Address - City:TINKER AFB
Practice Address - State:OK
Practice Address - Zip Code:73145
Practice Address - Country:US
Practice Address - Phone:405-736-4943
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1389363AM0700X
AK602363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical