Basic Information
| Provider Information | |||||||||
| NPI: | 1346293834 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BAKER | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12479 TELECOM DR | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336370913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139724199 | ||||||||
| FaxNumber: | 8139725753 | ||||||||
| Practice Location | |||||||||
| Address1: | 3100 E FLETCHER AVE | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336134613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139716000 | ||||||||
| FaxNumber: | 8136157590 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 11/05/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | E1775V | 01 | FL | BCBS OF FLORIDA | OTHER |