Provider Demographics
NPI:1679208391
Name:BAKER, AMY (MBBS)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:BAKER
Suffix:
Gender:F
Credentials:MBBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 GREENSBORO DRIVE
Mailing Address - Street 2:PO BOX 219
Mailing Address - City:BLACKSTOCK
Mailing Address - State:ONTARIO
Mailing Address - Zip Code:L0B1B0
Mailing Address - Country:CA
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 GREENSBORO DRIVE
Practice Address - Street 2:
Practice Address - City:BLACKSTOCK
Practice Address - State:ONTARIO
Practice Address - Zip Code:L0B1B0
Practice Address - Country:CA
Practice Address - Phone:757-931-8121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-18
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0116033404207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty