Provider Demographics
NPI:1609611730
Name:BACON, JOHN
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:BACON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31033 EDENDALE DR
Mailing Address - Street 2:
Mailing Address - City:WESLEY CHAPEL
Mailing Address - State:FL
Mailing Address - Zip Code:33543-6888
Mailing Address - Country:US
Mailing Address - Phone:813-442-2248
Mailing Address - Fax:
Practice Address - Street 1:3010 E 138TH AVE STE 12
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613-3999
Practice Address - Country:US
Practice Address - Phone:813-975-2800
Practice Address - Fax:813-977-7924
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-29
Last Update Date:2024-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11032861363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily