Basic Information
| Provider Information | |||||||||
| NPI: | 1144428541 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAKER | ||||||||
| FirstName: | CRYSTAL | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RPA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TRYON | ||||||||
| OtherFirstName: | CRYSTAL | ||||||||
| OtherMiddleName: | M | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 99 EAST STATE STREET | ||||||||
| Address2: | PO BOX 1250 | ||||||||
| City: | GLOVERSVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 120780010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5187754201 | ||||||||
| FaxNumber: | 5187754225 | ||||||||
| Practice Location | |||||||||
| Address1: | 99 EAST STATE STREET | ||||||||
| Address2: | MAB SUITE G01 | ||||||||
| City: | GLOVERSVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 120780010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5187754201 | ||||||||
| FaxNumber: | 5187754225 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2007 | ||||||||
| LastUpdateDate: | 01/21/2015 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 011908 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.