Provider Demographics
NPI:1346274727
Name:HARKER-BACCHUS, ANGELA R (NP)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:R
Last Name:HARKER-BACCHUS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18001 E 10 MILE RD
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48066-3803
Mailing Address - Country:US
Mailing Address - Phone:586-247-4300
Mailing Address - Fax:
Practice Address - Street 1:1500 EAST MEDICAL CENTER DRIVE
Practice Address - Street 2:UNIVERSITY HOSPITAL
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48109-5364
Practice Address - Country:US
Practice Address - Phone:734-888-2871
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2017-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704222689163W00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP00271409OtherRAILROAD MEDICARE
MI1038198OtherMCLAREN HEALTH PLAN-MEDICAID
MI4775320Medicaid
MI9160241OtherAETNA
MI1038198OtherMCLAREN HEALTH PLAN-COMMERCIAL
MI5008776940OtherBLUE CROSS BLUE SHIELD OF MICHIGAN
MI1038198OtherMCLAREN HEALTH ADVANTAGE
MI0N55170011OtherMEDICARE PLUS BLUE
MI1038198OtherMCLAREN HEALTH PLAN-MEDICAID
MIP00271409OtherRAILROAD MEDICARE