Healthcare Provider Details

I. General information

NPI: 1659346047
Provider Name (Legal Business Name): MICHAEL RUSSELL BAKER PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2006
Last Update Date: 02/04/2021
Certification Date: 02/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11704 W CENTER RD STE 200
OMAHA NE
68144-4375
US

IV. Provider business mailing address

11704 W CENTER RD STE 200
OMAHA NE
68144-4375
US

V. Phone/Fax

Practice location:
  • Phone: 402-691-0500
  • Fax: 402-505-6249
Mailing address:
  • Phone: 402-691-0500
  • Fax: 402-505-6249

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number196
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: