Healthcare Provider Details

I. General information

NPI: 1003868290
Provider Name (Legal Business Name): AMY L. BAKKER PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 11/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 22ND AVE.
BROOKINGS SD
57006-2497
US

IV. Provider business mailing address

400 22ND AVE.
BROOKINGS SD
57006-2497
US

V. Phone/Fax

Practice location:
  • Phone: 605-697-9500
  • Fax: 605-697-6939
Mailing address:
  • Phone: 605-697-9500
  • Fax: 605-697-6939

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0544
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: