Basic Information
| Provider Information | |||||||||
| NPI: | 1932341500 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BACA | ||||||||
| FirstName: | JUSTIN | ||||||||
| MiddleName: | THOMAS | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD, PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 933 BRADBURY DR SE STE 2222 | ||||||||
| Address2: | DEPARTMENT OF EMERGENCY MEDICINE | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871064375 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052723120 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1 UNIVERSITY OF NEW MEXICO # 116025 | ||||||||
| Address2: | DEPARTMENT OF EMERGENCY MEDICINE | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871310001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052725062 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2009 | ||||||||
| LastUpdateDate: | 07/29/2013 | ||||||||
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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 | 207P00000X | MD2013-0577 | NM | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.