Individual
KELLY BACON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
1301 E LINCOLN RD, IDABEL, OK 74745-7300
(580) 286-7623
Mailing address
PO BOX 1547, SEDALIA, MO 65302-1547
(660) 826-5960
Taxonomy
Speciality
Code
Description
License number
State
367500000X
Certified Registered Nurse Anesthetist
Primary
R0071221
OK
367H00000X
Anesthesiologist Assistant
R0071221
OK
Other
Enumeration date
05/03/2006
Last updated
10/26/2021
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