Healthcare Provider Details

I. General information

NPI: 1134818040
Provider Name (Legal Business Name): MARK BAKER SURGICAL ASSISTANT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2023
Last Update Date: 05/05/2023
Certification Date: 05/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 IRVING ST NW
WASHINGTON DC
20010-3017
US

IV. Provider business mailing address

12849 GALVESTON CT
MANASSAS VA
20112-8676
US

V. Phone/Fax

Practice location:
  • Phone: 202-877-6413
  • Fax:
Mailing address:
  • Phone: 703-232-2524
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: