Provider Demographics
NPI:1477265759
Name:BACCHUS, AYESHA
Entity Type:Individual
Prefix:
First Name:AYESHA
Middle Name:
Last Name:BACCHUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 S NEDDERMAN DR
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76019-9800
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7900 FARM TO MARKET ROAD 1826
Practice Address - Street 2:BLDG. 1, SUITE #220
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78737
Practice Address - Country:US
Practice Address - Phone:512-288-9669
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-19
Last Update Date:2023-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1102199363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics