Healthcare Provider Details

I. General information

NPI: 1396734687
Provider Name (Legal Business Name): ANDREW B BAKER CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/19/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 AVENUE H
POWELL WY
82435-2260
US

IV. Provider business mailing address

449 MOUNTAIN VIEW ST
POWELL WY
82435-2232
US

V. Phone/Fax

Practice location:
  • Phone: 307-754-2267
  • Fax:
Mailing address:
  • Phone: 307-754-4559
  • Fax: 307-754-7733

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number20840.283
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: