Provider Demographics
NPI:1164714325
Name:BACCHUS-MORRIS, AMANDA S (MD)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:S
Last Name:BACCHUS-MORRIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:S
Other - Last Name:BACCHUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:5055 E BROADWAY BLVD STE A100
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85711-3629
Mailing Address - Country:US
Mailing Address - Phone:520-327-0460
Mailing Address - Fax:
Practice Address - Street 1:6130 N LA CHOLLA BLVD STE 117
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85741
Practice Address - Country:US
Practice Address - Phone:520-207-7434
Practice Address - Fax:520-269-6897
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-06
Last Update Date:2018-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ44203207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ626390Medicaid
AZZ146871Medicare PIN