Provider Demographics
NPI:1710443122
Name:BAKER, MATILDA
Entity Type:Individual
Prefix:
First Name:MATILDA
Middle Name:
Last Name:BAKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3538
Mailing Address - Street 2:
Mailing Address - City:VAIL
Mailing Address - State:CO
Mailing Address - Zip Code:81658-3538
Mailing Address - Country:US
Mailing Address - Phone:571-438-5885
Mailing Address - Fax:
Practice Address - Street 1:181 W MEADOW DR
Practice Address - Street 2:
Practice Address - City:VAIL
Practice Address - State:CO
Practice Address - Zip Code:81657-5242
Practice Address - Country:US
Practice Address - Phone:970-476-1100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-11
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant