Wallace Bakers Mid-Level Group

Primary specialty

Medical Physician AssistantTaxonomy code 363AM0700X

License

M6919 Issued in ID

Legal business name

WALLACE BAKERS MID-LEVEL GROUP

Practice address

1880 John Adams Pkwy
Idaho Falls, ID 83401-4315

Phone

(208) 524-6633

Fax

(208) 524-9952

NPI assigned

May 29, 2007

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Dr. Wallace Coleman Baker, MDNPI 1083696967

Title

Ceo

Phone

(208) 524-6633

Specialties & licenses 1

Addresses

Other identifiers 1

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Wallace C Baker, M.D.

  • Family Medicine Physician
  • Idaho Falls, ID
  • NPI 1083696967
  NPD Authorized official
• Rebecca Jean Newby, PA-C

  • Physician Assistant
  • Idaho Falls, ID
  • NPI 1457685265
  NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1180396800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1639370810",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1880 JOHN ADAMS PKWY",
            "city": "IDAHO FALLS",
            "state": "ID",
            "postal_code": "834014315",
            "telephone_number": "208-524-6633",
            "fax_number": "208-524-9952"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1880 JOHN ADAMS PKWY",
            "city": "IDAHO FALLS",
            "state": "ID",
            "postal_code": "834014315",
            "telephone_number": "208-524-6633",
            "fax_number": "208-524-9952"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WALLACE BAKERS MID-LEVEL GROUP",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-05-29",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "BAKER",
        "authorized_official_first_name": "WALLACE",
        "authorized_official_middle_name": "COLEMAN",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "208-524-6633",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "363AM0700X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Physician Assistant, Medical",
            "state": "ID",
            "license": "M6919",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "8076593",
            "state": "ID"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Danae Lee Walker, FNP-C
• Eric D Walker, MD
• Jedd Douglas Walker, FNP-C
• Nevada Lee Walker
• Tanner Walker
• Wallace C Baker
• Gary Wayne Wallace, M.D.
• Misty Wallace
• Nicole L Wallace, I.S.
• Kayla Wallentine, PHARMD

• Medical Physician Assistant in Idaho Falls, ID
• Providers in Idaho Falls, ID by specialty
• Medical Physician Assistant in Idaho

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 22, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.