Provider Demographics
NPI:1083896567
Name:BACCUS, KATHEREN (CPNP)
Entity Type:Individual
Prefix:
First Name:KATHEREN
Middle Name:
Last Name:BACCUS
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1317 N HILLCREST DR
Mailing Address - Street 2:
Mailing Address - City:SULPHUR SPRINGS
Mailing Address - State:TX
Mailing Address - Zip Code:75482-2091
Mailing Address - Country:US
Mailing Address - Phone:903-438-1110
Mailing Address - Fax:903-438-1107
Practice Address - Street 1:1317 N HILLCREST DR
Practice Address - Street 2:
Practice Address - City:SULPHUR SPRINGS
Practice Address - State:TX
Practice Address - Zip Code:75482-2091
Practice Address - Country:US
Practice Address - Phone:903-438-1110
Practice Address - Fax:903-438-1107
Is Sole Proprietor?:No
Enumeration Date:2007-11-27
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX558304363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX198135905Medicaid
TX752950731OtherTAX ID
TX198135904Medicaid