Provider Demographics
NPI:1235753039
Name:BAKER, BRANDON T
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:T
Last Name:BAKER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 DESIARD ST STE 355
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-7363
Mailing Address - Country:US
Mailing Address - Phone:318-807-7875
Mailing Address - Fax:318-812-6603
Practice Address - Street 1:920 OLIVER RD # B
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-5702
Practice Address - Country:US
Practice Address - Phone:318-807-6267
Practice Address - Fax:318-812-6458
Is Sole Proprietor?:No
Enumeration Date:2020-06-08
Last Update Date:2020-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN142931163W00000X
LA214266363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse