Basic Information
| Provider Information | |||||||||
| NPI: | 1053650960 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BAKER | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | J. | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 428 | ||||||||
| Address2: | |||||||||
| City: | SHADY COVE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975390428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5418782022 | ||||||||
| FaxNumber: | 5418781498 | ||||||||
| Practice Location | |||||||||
| Address1: | 21990 HIGHWAY 62 | ||||||||
| Address2: | |||||||||
| City: | SHADY COVE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975399717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5418782022 | ||||||||
| FaxNumber: | 5418781498 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2013 | ||||||||
| LastUpdateDate: | 08/12/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 201350028NP | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 500655794 | 05 | OR | MEDICAID |