Provider Demographics
NPI:1598902231
Name:BAYLESS, MICHAEL DAVID JR
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:DAVID
Last Name:BAYLESS
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3020 RUCKER AVE
Mailing Address - Street 2:SUITE 106
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-3900
Mailing Address - Country:US
Mailing Address - Phone:425-339-5238
Mailing Address - Fax:
Practice Address - Street 1:3020 RUCKER AVE
Practice Address - Street 2:SUITE 106
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-3900
Practice Address - Country:US
Practice Address - Phone:425-339-5238
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-16
Last Update Date:2009-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAHC 60005661172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker