Provider Demographics
NPI:1285800466
Name:BAITANI, JESSICA R (MD)
Entity type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:R
Last Name:BAITANI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:BAITANI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:500 S MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:WACONIA
Mailing Address - State:MN
Mailing Address - Zip Code:55387-1791
Mailing Address - Country:US
Mailing Address - Phone:612-644-9905
Mailing Address - Fax:
Practice Address - Street 1:500 S MAPLE ST
Practice Address - Street 2:
Practice Address - City:WACONIA
Practice Address - State:MN
Practice Address - Zip Code:55387-1791
Practice Address - Country:US
Practice Address - Phone:952-441-2191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-07
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MN51659207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN19556OtherRESIDENT PERMIT