Provider Demographics
NPI: | 1659346047 |
---|---|
Name: | BAKER, MICHAEL RUSSELL (PA) |
Entity Type: | Individual |
Prefix: | MR |
First Name: | MICHAEL |
Middle Name: | RUSSELL |
Last Name: | BAKER |
Suffix: | |
Gender: | M |
Credentials: | PA |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 11704 W CENTER RD |
Mailing Address - Street 2: | STE 200 |
Mailing Address - City: | OMAHA |
Mailing Address - State: | NE |
Mailing Address - Zip Code: | 68144-4375 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 402-691-0500 |
Mailing Address - Fax: | 402-505-6249 |
Practice Address - Street 1: | 11704 W CENTER RD |
Practice Address - Street 2: | STE 200 |
Practice Address - City: | OMAHA |
Practice Address - State: | NE |
Practice Address - Zip Code: | 68144-4375 |
Practice Address - Country: | US |
Practice Address - Phone: | 402-691-0500 |
Practice Address - Fax: | 402-505-6249 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-02-21 |
Last Update Date: | 2021-02-04 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
NE | 196 | 363AS0400X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 363AS0400X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
NE | 196 | Other | NE PA LICENSE NMBR |
IA | R80756 | Other | IA BCBS PROVIDER NMBR |
NE | 196 | Other | NE PA LICENSE NMBR |
IA | R80756 | Other | IA BCBS PROVIDER NMBR |