Healthcare Provider Details

I. General information

NPI: 1710515077
Provider Name (Legal Business Name): NICHOLAS LYLE BAER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2020
Last Update Date: 10/14/2021
Certification Date: 10/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2820 E PARK AVE
CHIPPEWA FALLS WI
54729-3598
US

IV. Provider business mailing address

19024 64TH AVE
CHIPPEWA FALLS WI
54729-6727
US

V. Phone/Fax

Practice location:
  • Phone: 715-723-5542
  • Fax: 715-723-7957
Mailing address:
  • Phone: 608-865-0855
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5533
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: