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
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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:
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Provider Licenses
StateLicense IDTaxonomies
NE196363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE196OtherNE PA LICENSE NMBR
IAR80756OtherIA BCBS PROVIDER NMBR
NE196OtherNE PA LICENSE NMBR
IAR80756OtherIA BCBS PROVIDER NMBR