Provider Demographics
NPI:1487103370
Name:BACA, BRYAN M SR (MSN)
Entity type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:M
Last Name:BACA
Suffix:SR
Gender:M
Credentials:MSN
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Mailing Address - Street 1:10640 GATEWAY BLVD N
Mailing Address - Street 2:SUITE B
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79924-1700
Mailing Address - Country:US
Mailing Address - Phone:915-307-4936
Mailing Address - Fax:915-307-3683
Practice Address - Street 1:6211 EDGEMERE BLVD
Practice Address - Street 2:SUITE 1
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79925-3413
Practice Address - Country:US
Practice Address - Phone:915-881-8264
Practice Address - Fax:915-881-8082
Is Sole Proprietor?:No
Enumeration Date:2016-10-03
Last Update Date:2022-02-09
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Provider Licenses
StateLicense IDTaxonomies
TXAP131880363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily