Provider Demographics
NPI:1245982644
Name:BACA, MAYRA L (PNP)
Entity type:Individual
Prefix:
First Name:MAYRA
Middle Name:L
Last Name:BACA
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:MAYRA
Other - Middle Name:L
Other - Last Name:BACA HOLGUIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PNP
Mailing Address - Street 1:PO BOX 110429
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80042-0429
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13123 E 16TH AVE
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80045-7106
Practice Address - Country:US
Practice Address - Phone:720-777-1234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-26
Last Update Date:2022-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAPN.0997275-NP363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics