Provider Demographics
NPI:1528724812
Name:BACON, JOHN WILL (NP)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:WILL
Last Name:BACON
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:213 MIMS RD
Mailing Address - Street 2:
Mailing Address - City:SYLVANIA
Mailing Address - State:GA
Mailing Address - Zip Code:30467-1994
Mailing Address - Country:US
Mailing Address - Phone:912-303-7729
Mailing Address - Fax:912-564-2174
Practice Address - Street 1:213 MIMS RD
Practice Address - Street 2:
Practice Address - City:SYLVANIA
Practice Address - State:GA
Practice Address - Zip Code:30467-1994
Practice Address - Country:US
Practice Address - Phone:912-303-7729
Practice Address - Fax:912-564-2174
Is Sole Proprietor?:No
Enumeration Date:2021-11-11
Last Update Date:2025-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN245533363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner