Basic Information
| Provider Information | |||||||||
| NPI: | 1396049789 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BACA | ||||||||
| FirstName: | GLORIA | ||||||||
| MiddleName: | ANNETTE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3003 N CENTRAL AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850122914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6026856000 | ||||||||
| FaxNumber: | 6026856002 | ||||||||
| Practice Location | |||||||||
| Address1: | 3864 N 27TH AVE | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850174703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6026856000 | ||||||||
| FaxNumber: | 6029958503 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2010 | ||||||||
| LastUpdateDate: | 04/14/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 364SF0001X | RN063356 | AZ | N | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Family Health | 363LF0000X | AP0298 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 151233 | 05 | AZ | MEDICAID |