Basic Information
| Provider Information | |||||||||
| NPI: | 1710137658 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BAUER | ||||||||
| FirstName: | CAROLYN | ||||||||
| MiddleName: | A. | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | DEPT. 453 PO BOX 1000 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381480001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8285752625 | ||||||||
| FaxNumber: | 8283502174 | ||||||||
| Practice Location | |||||||||
| Address1: | 1651 GALISTEO ST STE 8 | ||||||||
| Address2: | |||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875054752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058209870 | ||||||||
| FaxNumber: | 5059831265 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2008 | ||||||||
| LastUpdateDate: | 05/19/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA20080043 | NM | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 636510AU6T | 01 | NM | MEDICARE PTAN | OTHER | 74909754 | 05 | NM | MEDICAID |