Provider Demographics
NPI:1902367196
Name:BAKER, NATHANIEL JR
Entity type:Individual
Prefix:MR
First Name:NATHANIEL
Middle Name:
Last Name:BAKER
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 BEAUREGARD DR
Mailing Address - Street 2:
Mailing Address - City:SPENCER
Mailing Address - State:NC
Mailing Address - Zip Code:28159-1956
Mailing Address - Country:US
Mailing Address - Phone:704-701-3309
Mailing Address - Fax:
Practice Address - Street 1:1900 W 1ST ST
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27104-4220
Practice Address - Country:US
Practice Address - Phone:704-701-3309
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-29
Last Update Date:2019-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6578224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant