Organization
WALLACE BAKERS MID-LEVEL GROUP
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. WALLACE COLEMAN BAKER MD (CEO)
(208) 524-6633
Entity
Organization
Contact information
Practice address
1880 JOHN ADAMS PKWY, IDAHO FALLS, ID 83401-4315
(208) 524-6633
(208) 524-9952
Mailing address
1880 JOHN ADAMS PKWY, IDAHO FALLS, ID 83401-4315
(208) 524-6633
(208) 524-9952
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
Primary
M6919
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
8076593
—
ID
Enumeration date
05/29/2007
Last updated
08/22/2020
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