Provider Demographics
NPI:1982030722
Name:BACHUS, KRISTEN DIANE (PA-C)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:DIANE
Last Name:BACHUS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 W IH 635 FWY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75063-3718
Mailing Address - Country:US
Mailing Address - Phone:972-406-1199
Mailing Address - Fax:972-556-2328
Practice Address - Street 1:440 W IH 635 FWY STE 405
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75063
Practice Address - Country:US
Practice Address - Phone:972-406-1199
Practice Address - Fax:972-556-2328
Is Sole Proprietor?:No
Enumeration Date:2013-09-25
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA08579363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX333618YKY6Medicare PIN