Provider Demographics
NPI:1518025360
Name:BAKER, SHANNON COOKE (MD)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:COOKE
Last Name:BAKER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2655 W 9000 S
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84088-8542
Mailing Address - Country:US
Mailing Address - Phone:801-256-6343
Mailing Address - Fax:801-256-6367
Practice Address - Street 1:2655 W 9000 S
Practice Address - Street 2:
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84088-8542
Practice Address - Country:US
Practice Address - Phone:801-256-6343
Practice Address - Fax:801-256-6367
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM7024207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX187932201Medicaid
TXP00662743OtherRAILROAD MEDICARE
TX187932202Medicaid
UT942854058645Medicaid
TX187932202Medicaid
TXI20586Medicare UPIN
UT942854058645Medicaid