Provider Demographics
NPI:1962508929
Name:BAKER, DEIDRA LYNN (NP)
Entity Type:Individual
Prefix:
First Name:DEIDRA
Middle Name:LYNN
Last Name:BAKER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:804 MEDICAL CIRCLE
Mailing Address - Street 2:SUITE G
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75605
Mailing Address - Country:US
Mailing Address - Phone:903-234-8030
Mailing Address - Fax:903-234-8039
Practice Address - Street 1:804 MEDICAL CIRCLE
Practice Address - Street 2:SUITE G
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605
Practice Address - Country:US
Practice Address - Phone:903-234-8030
Practice Address - Fax:903-234-8039
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2008-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX06786363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX184537201Medicaid
TX184537201Medicaid