Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LF0000X | Nurse Practitioner - Family Medicine | 863033 | WI |
NPI | 1003020322 |
---|---|
Provider Name | Mr. Ronald Glen Baker |
First Address | Stevens Point, WI 54481-6406 |
Second Address | Stevens Point, WI 54481-3105 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/05/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
43851000 | (05) | WI |
541171 | (02) | WI |