Provider Demographics
NPI:1861828808
Name:BAKER, RUSTY GENE (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MR
First Name:RUSTY
Middle Name:GENE
Last Name:BAKER
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1606 PROVIDENCE DR
Mailing Address - Street 2:
Mailing Address - City:MCHENRY
Mailing Address - State:IL
Mailing Address - Zip Code:60051-6974
Mailing Address - Country:US
Mailing Address - Phone:210-386-0579
Mailing Address - Fax:
Practice Address - Street 1:SURFACE WARFARE MEDICAL INSTITUTE
Practice Address - Street 2:34101 FARENHOLT AVENUE
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92134-0001
Practice Address - Country:US
Practice Address - Phone:619-532-7766
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-23
Last Update Date:2019-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program