Provider Demographics
NPI:1093204711
Name:BAKER, TODD RANDALL (PTA)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:RANDALL
Last Name:BAKER
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3628 NC 39 HWY N
Mailing Address - Street 2:
Mailing Address - City:LOUISBURG
Mailing Address - State:NC
Mailing Address - Zip Code:27549-6624
Mailing Address - Country:US
Mailing Address - Phone:919-218-6357
Mailing Address - Fax:
Practice Address - Street 1:114 SMOKETREE WAY
Practice Address - Street 2:
Practice Address - City:LOUISBURG
Practice Address - State:NC
Practice Address - Zip Code:27549-2117
Practice Address - Country:US
Practice Address - Phone:919-496-6084
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-08
Last Update Date:2018-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA4897225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant