Provider Demographics
NPI:1356509897
Name:BACA, KIRSTEN E (MD)
Entity Type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:E
Last Name:BACA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1407 N 2000 W
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:UT
Mailing Address - Zip Code:84015-8562
Mailing Address - Country:US
Mailing Address - Phone:385-333-7123
Mailing Address - Fax:
Practice Address - Street 1:1407 N 2000 W
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:UT
Practice Address - Zip Code:84015-8562
Practice Address - Country:US
Practice Address - Phone:385-333-7123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-31
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH16501207L00000X, 207LP2900X, 208VP0014X
UT9777824-1205208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine