Healthcare Provider Details

I. General information

NPI: 1861828808
Provider Name (Legal Business Name): RUSTY GENE BAKER PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2013
Last Update Date: 08/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

SURFACE WARFARE MEDICAL INSTITUTE 34101 FARENHOLT AVENUE
SAN DIEGO CA
92134-0001
US

IV. Provider business mailing address

1606 PROVIDENCE DR
MCHENRY IL
60051-6974
US

V. Phone/Fax

Practice location:
  • Phone: 619-532-7766
  • Fax:
Mailing address:
  • Phone: 210-386-0579
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: