Provider Demographics
NPI:1104928605
Name:BAKER, CLIFFORD EUGENE (NP)
Entity type:Individual
Prefix:MR
First Name:CLIFFORD
Middle Name:EUGENE
Last Name:BAKER
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11240 HIGHWAY 49
Mailing Address - Street 2:STE 300
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-4151
Mailing Address - Country:US
Mailing Address - Phone:228-284-4342
Mailing Address - Fax:228-284-4345
Practice Address - Street 1:11240 HIGHWAY 49
Practice Address - Street 2:STE 300
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-4151
Practice Address - Country:US
Practice Address - Phone:228-284-4342
Practice Address - Fax:228-284-4345
Is Sole Proprietor?:No
Enumeration Date:2006-09-04
Last Update Date:2015-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR690392363LF0000X
367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0116632Medicaid
MS0116632Medicaid
500000586Medicare ID - Type Unspecified