Healthcare Provider Details

I. General information

NPI: 1841015393
Provider Name (Legal Business Name): WYLIN BAKER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2024
Last Update Date: 11/20/2024
Certification Date: 11/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 MAJOR ALLEN ST
MARTIN SD
57551-6005
US

IV. Provider business mailing address

PO BOX 70
MARTIN SD
57551-0070
US

V. Phone/Fax

Practice location:
  • Phone: 605-685-6622
  • Fax:
Mailing address:
  • Phone: 605-280-8337
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1573
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: