Provider Demographics
NPI:1538682463
Name:BACH, THERESA
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:BACH
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 1:535 NW 9TH ST STE 325
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73102-1035
Mailing Address - Country:US
Mailing Address - Phone:405-272-6877
Mailing Address - Fax:405-272-6878
Practice Address - Street 1:535 NW 9TH ST STE 325
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73102-1035
Practice Address - Country:US
Practice Address - Phone:405-272-6877
Practice Address - Fax:405-272-6878
Is Sole Proprietor?:No
Enumeration Date:2017-07-23
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK103143363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner