Healthcare Provider Details

I. General information

NPI: 1972549947
Provider Name (Legal Business Name): SHIRLEY JEANNE BAKER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2006
Last Update Date: 09/12/2024
Certification Date: 09/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

623 W LASSATER
CENTERVILLE TX
75833-1959
US

IV. Provider business mailing address

1500 UNIVERSITY DR E #100
COLLEGE STATION TX
77840-2600
US

V. Phone/Fax

Practice location:
  • Phone: 903-289-1070
  • Fax: 936-744-1419
Mailing address:
  • Phone: 979-846-1100
  • Fax: 979-260-9390

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA02294
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: