Provider Demographics
NPI:1477557734
Name:BAKER, MICHELLE (PA)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
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 1:26850 PROVIDENCE PKWY
Mailing Address - Street 2:STE 200
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48374-1213
Mailing Address - Country:US
Mailing Address - Phone:248-465-3144
Mailing Address - Fax:248-465-3146
Practice Address - Street 1:22250 PROVIDENCE DRIVE
Practice Address - Street 2:5TH FLOOOR
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075
Practice Address - Country:US
Practice Address - Phone:248-849-3441
Practice Address - Fax:248-849-5389
Is Sole Proprietor?:No
Enumeration Date:2005-06-02
Last Update Date:2013-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5601003496363A00000X
363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N60410Medicare PIN