MEDICARE: AUTUMN K BAKER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	2000052738	MI

General Provider Information

NPI Number	:	1043998719
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AUTUMN K BAKER

Provider Business Mailing Address
First Line	:	4404 GLENOAKS CT
Second Line	:
City	:	WARREN
State	:	MI
Zip	:	48092-4196
Country	:	US
Telephone Number	:	313-939-8576
Fax Number	:

Provider Business Practice Location Address
First Line	:	4404 GLENOAKS CT
Second Line	:
City	:	WARREN
State	:	MI
Zip	:	48092-4196
Country	:	US
Telephone Number	:	313-939-8576
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/11/2023
Last Update Date	:	07/11/2023

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Directions to “ AUTUMN K BAKER ” Practice Location

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