Provider Demographics
NPI:1508169988
Name:BAKER, TIMOTHY J (CCP)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:J
Last Name:BAKER
Suffix:
Gender:M
Credentials:CCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15239 PORTICO LN
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336-1021
Mailing Address - Country:US
Mailing Address - Phone:909-740-4114
Mailing Address - Fax:909-591-8343
Practice Address - Street 1:15239 PORTICO LN
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92336-1021
Practice Address - Country:US
Practice Address - Phone:909-740-4114
Practice Address - Fax:909-591-8343
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-07
Last Update Date:2010-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NONE242T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes242T00000XTechnologists, Technicians & Other Technical Service ProvidersPerfusionist