1417625476 NPI number — NICHOLAS BAKER PA-C

Table of content: NICHOLAS BAKER PA-C (NPI 1417625476)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417625476 NPI number — NICHOLAS BAKER PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BAKER
Provider First Name:
NICHOLAS
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BAKER
Provider Other First Name:
NICK
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-S
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1417625476
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1643 NW 136TH AVE.
Provider Second Line Business Mailing Address:
BLDG: H, SUITE: 100 MSC 11607-0004
Provider Business Mailing Address City Name:
SUNRISE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33323
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
785-224-6780
Provider Business Mailing Address Fax Number:
865-560-7110

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2611 S DEARBORN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SEATTLE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98144-3013
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-712-6500
Provider Business Practice Location Address Fax Number:
865-560-7110
Provider Enumeration Date:
09/02/2021

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AM0700X , with the licence number: PA61358792 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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