Provider Demographics
NPI:1558826784
Name:BACCUS, SAVANAH NICOLE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:SAVANAH
Middle Name:NICOLE
Last Name:BACCUS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SAVANAH
Other - Middle Name:NICOLE
Other - Last Name:HADLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4760 E. BASELINE ROAD
Mailing Address - Street 2:APT. 2108
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206
Mailing Address - Country:US
Mailing Address - Phone:947-522-1860
Mailing Address - Fax:947-522-0307
Practice Address - Street 1:44201 DEQUINDRE RD
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48085-1117
Practice Address - Country:US
Practice Address - Phone:248-964-5000
Practice Address - Fax:248-964-4848
Is Sole Proprietor?:No
Enumeration Date:2019-02-01
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8106363AS0400X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical