Provider Demographics
NPI:1912909789
Name:BAKER, BRET ALAN (PA)
Entity Type:Individual
Prefix:
First Name:BRET
Middle Name:ALAN
Last Name:BAKER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4222 WENDOVER AVE
Mailing Address - Street 2:SUITE 600
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79762-5945
Mailing Address - Country:US
Mailing Address - Phone:432-552-5656
Mailing Address - Fax:432-552-0992
Practice Address - Street 1:4222 WENDOVER AVE
Practice Address - Street 2:SUITE 600
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79762-5945
Practice Address - Country:US
Practice Address - Phone:432-552-5656
Practice Address - Fax:432-552-0992
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03994363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA03994OtherTX LICENSE NUMBER
TXPA03994OtherTX LICENSE NUMBER