Basic Information
| Provider Information | |||||||||
| NPI: | 1679654909 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BACHINSKI | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | LAVERNE | ||||||||
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| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5450 WESTERN AVE | ||||||||
| Address2: | SUITE B | ||||||||
| City: | BOULDER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 803012709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034154770 | ||||||||
| FaxNumber: | 3034154769 | ||||||||
| Practice Location | |||||||||
| Address1: | 2101 KEN PRATT BLVD | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | LONGMONT | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805016567 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034154157 | ||||||||
| FaxNumber: | 3037763102 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2006 | ||||||||
| LastUpdateDate: | 08/24/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA.0000246 | CO | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | PA.0000246 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 07002462 | 05 | CO | MEDICAID |