Provider Demographics
NPI:1811243462
Name:BACA, JEROME WAYNE (PA-C)
Entity type:Individual
Prefix:
First Name:JEROME
Middle Name:WAYNE
Last Name:BACA
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 1:6701 JEFFERSON ST NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-4318
Mailing Address - Country:US
Mailing Address - Phone:505-727-6200
Mailing Address - Fax:505-727-9590
Practice Address - Street 1:6701 JEFFERSON ST NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109
Practice Address - Country:US
Practice Address - Phone:505-727-6200
Practice Address - Fax:505-727-9590
Is Sole Proprietor?:No
Enumeration Date:2012-08-01
Last Update Date:2019-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2012-0025363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM64471870Medicaid
NMPA2012-0025OtherNM MEDICAL LICENSE