Individual
WILLIAM T BACON IV
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
1650 HOSPITAL DR STE 500, SANTA FE, NM 87505-4794
(505) 670-1976
(505) 983-7212
Mailing address
1650 HOSPITAL DR STE 500, SANTA FE, NM 87505-4794
(505) 670-1976
(505) 983-7212
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
Primary
2001-PA36
NM
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
05638852
—
NM
Enumeration date
06/01/2005
Last updated
03/06/2025
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