MEDICARE: DR. JONATHAN GLENN BAKER M.D.

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	207N00000X	Dermatology Physician	8097A	WY
2	207N00000X	Dermatology Physician	A55560	CA

General Provider Information

NPI Number	:	1447233754
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JONATHAN GLENN BAKER M.D.

Provider Business Mailing Address
First Line	:	PO BOX 14510
Second Line	:
City	:	JACKSON
State	:	WY
Zip	:	83002-4510
Country	:	US
Telephone Number	:	307-734-1800
Fax Number	:	307-734-5012

Provider Business Practice Location Address
First Line	:	984 WEST BROADWAY
Second Line	:	SUITE 4
City	:	JACKSON
State	:	WY
Zip	:	83001-0000
Country	:	US
Telephone Number	:	307-734-1800
Fax Number	:	307-734-5012

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

Provider Enumeration Date	:	11/22/2005
Last Update Date	:	08/04/2014

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