Provider Demographics
NPI:1053650960
Name:BAKER, MARY J (FNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:J
Last Name:BAKER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 428
Mailing Address - Street 2:
Mailing Address - City:SHADY COVE
Mailing Address - State:OR
Mailing Address - Zip Code:97539-0428
Mailing Address - Country:US
Mailing Address - Phone:541-878-2022
Mailing Address - Fax:541-878-1498
Practice Address - Street 1:21990 HIGHWAY 62
Practice Address - Street 2:
Practice Address - City:SHADY COVE
Practice Address - State:OR
Practice Address - Zip Code:97539-9717
Practice Address - Country:US
Practice Address - Phone:541-878-2022
Practice Address - Fax:541-878-1498
Is Sole Proprietor?:No
Enumeration Date:2013-02-13
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201350028NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500655794Medicaid
OR500655794Medicaid