Provider Demographics
NPI:1902168669
Name:BACON, WILLIAM JOHN (PTA)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:JOHN
Last Name:BACON
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:902 E. 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:WEBSTER
Mailing Address - State:SD
Mailing Address - Zip Code:57274
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:902 E 12TH AVE
Practice Address - Street 2:
Practice Address - City:WEBSTER
Practice Address - State:SD
Practice Address - Zip Code:57274-2300
Practice Address - Country:US
Practice Address - Phone:956-451-1907
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-08
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2061050171W00000X
NY008793225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No171W00000XOther Service ProvidersContractor