Provider Demographics
NPI:1093138265
Name:BACCUS, JOHN ALAN (RT, CRT-NPS, RST)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ALAN
Last Name:BACCUS
Suffix:
Gender:M
Credentials:RT, CRT-NPS, RST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5000 EL DORADO PARKWAY, SUITE 150
Mailing Address - Street 2:BOX 312
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75033
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5000 EL DORADO PARKWAY, SUITE 150
Practice Address - Street 2:BOX 312
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75033
Practice Address - Country:US
Practice Address - Phone:940-391-7155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-24
Last Update Date:2014-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1205839743Medicare PIN