Provider Demographics
NPI:1518591692
Name:BAKER, ETHAN ARTHUR (LAC)
Entity Type:Individual
Prefix:MR
First Name:ETHAN
Middle Name:ARTHUR
Last Name:BAKER
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 W. 99TH ST.
Mailing Address - Street 2:APT. 8B
Mailing Address - City:NEW YORK CITY
Mailing Address - State:NY
Mailing Address - Zip Code:10025
Mailing Address - Country:US
Mailing Address - Phone:212-496-8923
Mailing Address - Fax:
Practice Address - Street 1:309 W. 99TH ST.
Practice Address - Street 2:APT. 8B
Practice Address - City:NEW YORK CITY
Practice Address - State:NY
Practice Address - Zip Code:10025
Practice Address - Country:US
Practice Address - Phone:212-496-8923
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-27
Last Update Date:2020-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006189-1171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist