Basic Information
| Provider Information | |||||||||
| NPI: | 1972109742 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BACA | ||||||||
| FirstName: | ANDREWE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12 CALLE CRISTOVAL | ||||||||
| Address2: | |||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875073716 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | MSC08 4700 01 UNIVERSITY OF NEW MEXICO | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871312719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052723414 | ||||||||
| FaxNumber: | 5052728239 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2020 | ||||||||
| LastUpdateDate: | 11/13/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.