Provider Demographics
NPI:1730181942
Name:BACON, WILLIAM T IV (PA-C)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:T
Last Name:BACON
Suffix:IV
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 1:1650 HOSPITAL DR STE 500
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-4794
Mailing Address - Country:US
Mailing Address - Phone:505-670-1976
Mailing Address - Fax:505-983-7212
Practice Address - Street 1:1650 HOSPITAL DR STE 500
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4794
Practice Address - Country:US
Practice Address - Phone:505-670-1976
Practice Address - Fax:505-983-7212
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2025-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2001-PA36363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM05638852Medicaid
NM05638852Medicaid
NMNMA100359Medicare PIN