MEDICARE: MRS. TRISHA ANN BACKUS RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	149463030	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1316133960
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TRISHA ANN BACKUS RN

Provider Business Mailing Address
First Line	:	1118 DIVISION ST
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54303-3002
Country	:	US
Telephone Number	:	920-884-9981
Fax Number	:

Provider Business Practice Location Address
First Line	:	1118 DIVISION ST
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54303-3002
Country	:	US
Telephone Number	:	920-884-9981
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/18/2007
Last Update Date	:	04/09/2010

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