Provider Demographics
NPI:1407884950
Name:BAKER, KENNETH E (PA-C)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:E
Last Name:BAKER
Suffix:
Gender:M
Credentials:PA-C
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 4059
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07474-4059
Mailing Address - Country:US
Mailing Address - Phone:973-826-8291
Mailing Address - Fax:888-972-4761
Practice Address - Street 1:4215 EDGEWATER DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32804-2206
Practice Address - Country:US
Practice Address - Phone:407-539-2000
Practice Address - Fax:407-398-0050
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010532363AM0700X
FLPA9100970363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLCU700YOtherQSS SCS MEDICARE PTAN
FLHF826AOtherQSS SCS GROUP PTAN
FLCU700YOtherQSS SCS MEDICARE PTAN
FLHF826AOtherQSS SCS GROUP PTAN
S89067Medicare UPIN
FLCU700ZMedicare PIN