Basic Information
| Provider Information | |||||||||
| NPI: | 1245846187 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BAKER | ||||||||
| FirstName: | ADAM | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 789 WASHINGTON ST W | ||||||||
| Address2: | |||||||||
| City: | VALE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 979181147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414732101 | ||||||||
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| Practice Location | |||||||||
| Address1: | 271 JEFFERSON ST | ||||||||
| Address2: | |||||||||
| City: | BLACKFOOT | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832211818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082215051 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2020 | ||||||||
| LastUpdateDate: | 09/16/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.