Provider Demographics
NPI:1972133254
Name:BACCHUS, SHAZAM (APN)
Entity Type:Individual
Prefix:
First Name:SHAZAM
Middle Name:
Last Name:BACCHUS
Suffix:
Gender:M
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:459 N 7TH ST FL 1
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07107-3743
Mailing Address - Country:US
Mailing Address - Phone:973-388-9560
Mailing Address - Fax:
Practice Address - Street 1:459 N 7TH ST FL 1
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07107-3743
Practice Address - Country:US
Practice Address - Phone:973-388-9560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-24
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ01004000363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care