Basic Information
| Provider Information | |||||||||
| NPI: | 1063067965 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BACONG | ||||||||
| FirstName: | AUSTIN | ||||||||
| MiddleName: | MATIAS | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9827 N 95TH ST STE 105 | ||||||||
| Address2: | |||||||||
| City: | SCOTTSDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852584591 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808608488 | ||||||||
| FaxNumber: | 4808608498 | ||||||||
| Practice Location | |||||||||
| Address1: | 9827 N 95TH ST STE 105 | ||||||||
| Address2: | |||||||||
| City: | SCOTTSDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852584591 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808608488 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2019 | ||||||||
| LastUpdateDate: | 08/07/2019 | ||||||||
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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 | 7519 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.