Healthcare Provider Details

I. General information

NPI: 1063709335
Provider Name (Legal Business Name): GAVIN NATHAN BAKER CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2011
Last Update Date: 04/04/2023
Certification Date: 04/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 W MICHIGAN AVE
JACKSON MI
49201-2218
US

IV. Provider business mailing address

3510 N CAUSEWAY BLVD SUITE 404
METAIRIE LA
70002-3531
US

V. Phone/Fax

Practice location:
  • Phone: 800-516-5315
  • Fax: 517-787-7365
Mailing address:
  • Phone: 504-779-5515
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN117613
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAP06485
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: