Provider Demographics
NPI:1063067965
Name:BACONG, AUSTIN MATIAS (PA-C)
Entity type:Individual
Prefix:MR
First Name:AUSTIN
Middle Name:MATIAS
Last Name:BACONG
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9827 N 95TH ST STE 105
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85258-4591
Mailing Address - Country:US
Mailing Address - Phone:480-860-8488
Mailing Address - Fax:480-860-8498
Practice Address - Street 1:9827 N 95TH ST STE 105
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85258-4591
Practice Address - Country:US
Practice Address - Phone:480-860-8488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-07
Last Update Date:2019-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7519363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant