Provider Demographics
NPI:1770774648
Name:BAKER, BRENT WYATT (PA-C)
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:WYATT
Last Name:BAKER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1410 W JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:WAXAHACHIE
Mailing Address - State:TX
Mailing Address - Zip Code:75165-2232
Mailing Address - Country:US
Mailing Address - Phone:972-937-1210
Mailing Address - Fax:972-937-0243
Practice Address - Street 1:1410 W JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:WAXAHACHIE
Practice Address - State:TX
Practice Address - Zip Code:75165-2232
Practice Address - Country:US
Practice Address - Phone:972-937-1210
Practice Address - Fax:972-937-0243
Is Sole Proprietor?:No
Enumeration Date:2007-08-06
Last Update Date:2014-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04634363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX217344504Medicaid