Individual
JEROME WAYNE BACA
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
6701 JEFFERSON ST NE, ALBUQUERQUE, NM 87109
(505) 727-6200
(505) 727-9590
Mailing address
6701 JEFFERSON ST NE, ALBUQUERQUE, NM 87109-4318
(505) 727-6200
(505) 727-9590
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
Primary
PA2012-0025
NM
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
64471870
—
NM
01
—
PA2012-0025
NM MEDICAL LICENSE
NM
Enumeration date
08/01/2012
Last updated
11/07/2019
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