Healthcare Provider Details

I. General information

NPI: 1851421374
Provider Name (Legal Business Name): BERT MANFRED BAKER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 05/18/2021
Certification Date: 05/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MADIGAN ARMY MEDICAL CENTER 9040 JACKSON AVE
TACOMA WA
98431-0001
US

IV. Provider business mailing address

4141 S STAPLES ST STE 300
CORPUS CHRISTI TX
78411-0002
US

V. Phone/Fax

Practice location:
  • Phone: 253-968-2252
  • Fax:
Mailing address:
  • Phone: 253-968-2252
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberPA02190
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: