Provider Demographics
NPI:1417389511
Name:SY, BABA
Entity Type:Individual
Prefix:
First Name:BABA
Middle Name:
Last Name:SY
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 1:2025 E 73RD AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99507-2789
Mailing Address - Country:US
Mailing Address - Phone:907-222-6855
Mailing Address - Fax:907-222-2653
Practice Address - Street 1:3760 W 74TH AVE
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99502-2862
Practice Address - Country:US
Practice Address - Phone:907-350-0061
Practice Address - Fax:907-868-1592
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-31
Last Update Date:2020-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK978570103TA0700X
AK372500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes372500000XNursing Service Related ProvidersChore ProviderGroup - Single Specialty
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1417389511Medicaid