Provider Demographics
NPI:1598858383
Name:BAKER, PAUL M (CRNA)
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:M
Last Name:BAKER
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2015 VAN ST
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38804-1043
Mailing Address - Country:US
Mailing Address - Phone:270-564-0024
Mailing Address - Fax:
Practice Address - Street 1:2015 VAN ST
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38804-1043
Practice Address - Country:US
Practice Address - Phone:270-564-0024
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2013-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1565A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY74407354Medicaid
P00261306OtherRAILROAD MEDICARE
000000361080OtherBCBS
0957002Medicare ID - Type Unspecified
KY74407354Medicaid