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General NPI Number Information
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NPI Number | 1134140148
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Entity Type | Organization
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Legal Business Name | WALLACE C BAKER
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Dates
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Enumeration Date | 07/22/2006
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Last Update Date | 07/19/2010
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Provider Practice Location Address
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Address Line | 1880 JOHN ADAMS PKWY
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City | IDAHO FALLS
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State | ID
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Zip | 83401-4315
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Country | US
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Telephone | 208-524-6633
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Fax | 208-524-9952
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Provider Business Mailing Address
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Address Line | 1880 JOHN ADAMS PKWY
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City | IDAHO FALLS
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State | ID
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Zip | 83401-4315
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Country | US
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Telephone | 208-524-6633
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Fax | 208-524-9952
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Authorized Official
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Title or Position | DOCTOR
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Name | DR. WALLACE C. BAKER
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Credential | M.D.
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Telephone | 208-524-6633
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | M6919
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License Number State | ID
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