Basic Information
| Provider Information | |||||||||
| NPI: | 1710558598 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BAEZ | ||||||||
| FirstName: | MAICO | ||||||||
| MiddleName: | JULIAN | ||||||||
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| NameSuffix: | SR. | ||||||||
| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5679 KYLES LN | ||||||||
| Address2: | |||||||||
| City: | LIBERTY TOWNSHIP | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450449462 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5132556566 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10500 MONTGOMERY RD | ||||||||
| Address2: | |||||||||
| City: | MONTGOMERY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452424402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5138651111 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2021 | ||||||||
| LastUpdateDate: | 07/02/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | APRN.CNP.0029198 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
No ID Information.