Provider Demographics
NPI:1528334166
Name:BACALIS, PAUL R
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:R
Last Name:BACALIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:PAUL
Other - Middle Name:R
Other - Last Name:BACALIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:APN-NP
Mailing Address - Street 1:PO BOX 912215
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80291-2215
Mailing Address - Country:US
Mailing Address - Phone:303-306-7783
Mailing Address - Fax:303-306-7753
Practice Address - Street 1:1024 S LEMAY AVE
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524-3929
Practice Address - Country:US
Practice Address - Phone:970-495-7000
Practice Address - Fax:303-306-7753
Is Sole Proprietor?:No
Enumeration Date:2012-03-28
Last Update Date:2016-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COC-APN.0000174-C-NP363L00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN500007591Medicare PIN