Provider Demographics
NPI:1912292020
Name:BACA, VANESSA G (APRN)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:G
Last Name:BACA
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 N HILLSIDE ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67214-4910
Mailing Address - Country:US
Mailing Address - Phone:316-962-7190
Mailing Address - Fax:316-962-7100
Practice Address - Street 1:848 N SAINT FRANCIS ST
Practice Address - Street 2:STE 3950
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67214-3800
Practice Address - Country:US
Practice Address - Phone:316-268-5591
Practice Address - Fax:316-291-7890
Is Sole Proprietor?:No
Enumeration Date:2011-06-16
Last Update Date:2017-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS5375128363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200568390AMedicaid
OK200568390AMedicaid