Provider Demographics
NPI:1275771610
Name:BAKER, SALLY SUE (PA)
Entity Type:Individual
Prefix:MS
First Name:SALLY
Middle Name:SUE
Last Name:BAKER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2120 EXCHANGE ST
Mailing Address - Street 2:111
Mailing Address - City:ASTORIA
Mailing Address - State:OR
Mailing Address - Zip Code:97103-3365
Mailing Address - Country:US
Mailing Address - Phone:503-325-0333
Mailing Address - Fax:503-325-6333
Practice Address - Street 1:2120 EXCHANGE ST
Practice Address - Street 2:111
Practice Address - City:ASTORIA
Practice Address - State:OR
Practice Address - Zip Code:97103-3365
Practice Address - Country:US
Practice Address - Phone:503-325-0333
Practice Address - Fax:503-325-6333
Is Sole Proprietor?:No
Enumeration Date:2009-01-22
Last Update Date:2009-01-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OR01141363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical