Healthcare Provider Details

I. General information

NPI: 1447247648
Provider Name (Legal Business Name): J TODD BAKER CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/03/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 FOOTHILL DR
SLC UT
84148-0001
US

IV. Provider business mailing address

1634 GRANADA DR
SANDY UT
84093-3744
US

V. Phone/Fax

Practice location:
  • Phone: 801-584-1240
  • Fax:
Mailing address:
  • Phone: 801-553-0306
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number188283-4406
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: