Provider Demographics
NPI:1396049789
Name:BACA, GLORIA ANNETTE (FNP)
Entity type:Individual
Prefix:MRS
First Name:GLORIA
Middle Name:ANNETTE
Last Name:BACA
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3003 N CENTRAL AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2914
Mailing Address - Country:US
Mailing Address - Phone:602-685-6000
Mailing Address - Fax:602-685-6002
Practice Address - Street 1:3864 N 27TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85017-4703
Practice Address - Country:US
Practice Address - Phone:602-685-6000
Practice Address - Fax:602-995-8503
Is Sole Proprietor?:No
Enumeration Date:2010-12-29
Last Update Date:2015-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN063356364SF0001X
AZAP0298363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ151233Medicaid
AZZ167842Medicare PIN