Provider Demographics
NPI:1417625476
Name:BAKER, NICHOLAS (PA-C)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:BAKER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:NICK
Other - Middle Name:
Other - Last Name:BAKER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-S
Mailing Address - Street 1:1643 NW 136TH AVE.
Mailing Address - Street 2:BLDG: H, SUITE: 100 MSC 11607-0004
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33323
Mailing Address - Country:US
Mailing Address - Phone:785-224-6780
Mailing Address - Fax:865-560-7110
Practice Address - Street 1:2611 S DEARBORN ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98144-3013
Practice Address - Country:US
Practice Address - Phone:206-712-6500
Practice Address - Fax:865-560-7110
Is Sole Proprietor?:No
Enumeration Date:2021-09-02
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WAPA61358792363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program