1720040157 NPI number — MR. FRED POWELL BAKER JR. RN-PMHNP-BC

Table of content: MR. FRED POWELL BAKER JR. RN-PMHNP-BC (NPI 1720040157)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720040157 NPI number — MR. FRED POWELL BAKER JR. RN-PMHNP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BAKER
Provider First Name:
FRED
Provider Middle Name:
POWELL
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
RN-PMHNP-BC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1720040157
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/23/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7901 METROPOLIS DR
Provider Second Line Business Mailing Address:
VA OUTPATIENT CLINIC
Provider Business Mailing Address City Name:
AUSTIN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78744-3111
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-823-4342
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7901 METROPOLIS DR # 78744
Provider Second Line Business Practice Location Address:
VA OUTPATIENT CLINIC
Provider Business Practice Location Address City Name:
AUSTIN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78744-3111
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-823-4342
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/03/2006

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: 363LP0808X , with the licence number:  529711 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 364SP0808X , with the licence number: RN LIC. NO. 529711 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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