Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207W00000X | Ophthalmologist | K4359 | TX |
NPI | 1023016177 |
---|---|
Provider Name | Dr. Wendy Baca |
First Address | San Antonio, TX 78265-5165 |
Second Address | San Antonio, TX 78230 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 12/07/2005 |
Last Update Date | 01/09/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
8CC564 | BLUE CROSS OF TEXAS (01) | TX |
8F22359 | MEDICARE IND PTAN (01) | TX |
G78812 | (02) | TX |