Provider Demographics
NPI:1124188404
Name:BAISCH, MINA (NP)
Entity Type:Individual
Prefix:
First Name:MINA
Middle Name:
Last Name:BAISCH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3601 A ST
Mailing Address - Street 2:ATTN: CREDENTIALING
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19134-1043
Mailing Address - Country:US
Mailing Address - Phone:413-588-4838
Mailing Address - Fax:215-427-4316
Practice Address - Street 1:3601 A ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19134-1043
Practice Address - Country:US
Practice Address - Phone:413-588-4838
Practice Address - Fax:215-427-4316
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-09
Last Update Date:2013-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2257867208000000X
PASP013211363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q63779Medicare UPIN