Provider Demographics
NPI:1104078054
Name:BAJACKSON, SUE WHALEY (RN,MSN,FNP-C)
Entity type:Individual
Prefix:
First Name:SUE
Middle Name:WHALEY
Last Name:BAJACKSON
Suffix:
Gender:F
Credentials:RN,MSN,FNP-C
Other - Prefix:
Other - First Name:MARTHA
Other - Middle Name:SUE
Other - Last Name:WHALEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN-C,MSN,FNP-C
Mailing Address - Street 1:175 MARY MAX CIR
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:TX
Mailing Address - Zip Code:78666-3254
Mailing Address - Country:US
Mailing Address - Phone:956-434-1377
Mailing Address - Fax:
Practice Address - Street 1:175 MARY MAX CIR
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:TX
Practice Address - Zip Code:78666-3254
Practice Address - Country:US
Practice Address - Phone:956-434-1377
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-22
Last Update Date:2025-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP102784363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care