Provider Demographics
NPI:1124046370
Name:BAKER, GEORGE M (PA-C)
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:M
Last Name:BAKER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1055 N 500 W
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-3305
Mailing Address - Country:US
Mailing Address - Phone:801-354-8225
Mailing Address - Fax:801-418-0941
Practice Address - Street 1:97 PROFESSIONAL WAY
Practice Address - Street 2:SUITE 2
Practice Address - City:PAYSON
Practice Address - State:UT
Practice Address - Zip Code:84651-1614
Practice Address - Country:US
Practice Address - Phone:801-465-4896
Practice Address - Fax:801-465-4107
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT267162-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S92563Medicare UPIN
005560104Medicare ID - Type Unspecified