Basic Information
| Provider Information | |||||||||
| NPI: | 1467689166 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BAKER | ||||||||
| FirstName: | DROSTAN | ||||||||
| MiddleName: | GREGG | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2003 KOOTENAI HEALTH WAY | ||||||||
| Address2: | |||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838146051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086255085 | ||||||||
| FaxNumber: | 2086255731 | ||||||||
| Practice Location | |||||||||
| Address1: | 2207 N MOLTER RD STE 203 | ||||||||
| Address2: | |||||||||
| City: | LIBERTY LAKE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 99019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095658803 | ||||||||
| FaxNumber: | 5098423057 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2009 | ||||||||
| LastUpdateDate: | 08/20/2019 | ||||||||
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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 | 207Q00000X | M13734 | ID | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | MD60250792 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00 | 01 | WA | RESIDENT | OTHER |