Basic Information
| Provider Information | |||||||||
| NPI: | 1164714325 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BACCHUS-MORRIS | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BACCHUS | ||||||||
| OtherFirstName: | AMANDA | ||||||||
| OtherMiddleName: | S | ||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5055 E BROADWAY BLVD STE A100 | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857113629 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5203270460 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6130 N LA CHOLLA BLVD STE 117 | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85741 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5202077434 | ||||||||
| FaxNumber: | 5202696897 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2011 | ||||||||
| LastUpdateDate: | 09/04/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 44203 | AZ | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 626390 | 05 | AZ | MEDICAID |