Provider Demographics
NPI:1730163239
Name:BACANI, ANDREA KIRSTIN (MD)
Entity type:Individual
Prefix:DR
First Name:ANDREA
Middle Name:KIRSTIN
Last Name:BACANI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:801-387-7125
Mailing Address - Fax:
Practice Address - Street 1:4403 HARRISON BLVD
Practice Address - Street 2:STE 3650
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-3271
Practice Address - Country:US
Practice Address - Phone:801-387-7125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2011-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ34524207R00000X
MN103872207RR0500X
MN51043207RR0500X
UT8027519-1205207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ223832Medicaid
MNP00728951OtherRAILROAD MEDICARE
MNENROLLEDMedicaid
MNENROLLEDMedicaid
AZ223832Medicaid