Healthcare Provider Details

I. General information

NPI: 1710443122
Provider Name (Legal Business Name): MATILDA BAKER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/11/2019
Last Update Date: 07/27/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

181 W MEADOW DR
VAIL CO
81657-5242
US

IV. Provider business mailing address

181 W MEADOW DR STE 400
VAIL CO
81657-5058
US

V. Phone/Fax

Practice location:
  • Phone: 970-476-1100
  • Fax:
Mailing address:
  • Phone: 970-680-0795
  • Fax: 970-479-5835

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA.0005742
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.0005742
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: