Healthcare Provider Details

I. General information

NPI: 1912152562
Provider Name (Legal Business Name): JASON LEE BAKER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/24/2008
Last Update Date: 05/25/2021
Certification Date: 05/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 FALCON PKWY
SCHRIEVER AFB CO
80912-5005
US

IV. Provider business mailing address

220 FALCON PKWY
SCHRIEVER AFB CO
80912-5005
US

V. Phone/Fax

Practice location:
  • Phone: 719-567-5536
  • Fax: 719-567-5115
Mailing address:
  • Phone: 937-581-6529
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1086035
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: