Healthcare Provider Details

I. General information

NPI: 1891425765
Provider Name (Legal Business Name): LUKE BAKER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2022
Last Update Date: 11/16/2023
Certification Date: 11/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 VINCENNES ST
NEW ALBANY IN
47150-3152
US

IV. Provider business mailing address

4234 SILVER GLADE TRL
SELLERSBURG IN
47172-1773
US

V. Phone/Fax

Practice location:
  • Phone: 812-542-8506
  • Fax:
Mailing address:
  • Phone: 502-410-8143
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number36003745A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: