Provider Demographics
NPI:1043663818
Name:BAKER, KELLY (PAC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:BAKER
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:BROCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:9000 W WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4874
Mailing Address - Country:US
Mailing Address - Phone:414-266-6457
Mailing Address - Fax:414-266-2294
Practice Address - Street 1:9000 W WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-4874
Practice Address - Country:US
Practice Address - Phone:414-266-6457
Practice Address - Fax:414-266-2294
Is Sole Proprietor?:No
Enumeration Date:2016-07-18
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3828363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1043663818Medicaid