| Doctor Name: | MR. MARK ROBERT BACON |
| NPI Number: | 1972530053 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | PA-C |
| License Number: | 602 |
| Business Practice Address: | 72nd Medical Group 5700 Arnold St Tinker Afb, OK - 73145 |
| Business Phone Number: | 4057364943 |
| Business Fax Number: | |
| Mailing Address: | 748 Milan Ct, EDMOND |
| State: | OK |
| Postal Code: | 730346897 |
| Phone Number: | 4053304946 |
| Fax Number: | |
| NPI Enumeration Date: | 06/26/2006 |
| NPI Last Update Date: | 07/08/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 363AM0700X |
| License Number: | 602 |
| Healthcare Provider Taxonomy: (Secondary) | N |
| State: | AK |
| Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
| Taxonomy Classification: | Physician Assistant |
| Taxonomy Specialization: | Medical |
| Taxonomy Definition: | |