Provider Demographics
NPI:1568466811
Name:BACA, LORETTA L (MD)
Entity Type:Individual
Prefix:
First Name:LORETTA
Middle Name:L
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 1:302 S JEFFERS ST
Mailing Address - Street 2:
Mailing Address - City:NORTH PLATTE
Mailing Address - State:NE
Mailing Address - Zip Code:69101-5349
Mailing Address - Country:US
Mailing Address - Phone:308-534-6687
Mailing Address - Fax:308-534-1874
Practice Address - Street 1:302 S JEFFERS ST
Practice Address - Street 2:
Practice Address - City:NORTH PLATTE
Practice Address - State:NE
Practice Address - Zip Code:69101-5349
Practice Address - Country:US
Practice Address - Phone:308-534-6687
Practice Address - Fax:308-534-1874
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2009-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE19678207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47-0822695-13Medicaid
NEE65648Medicare UPIN
NE47-0822695-13Medicaid