Provider Demographics
NPI:1225119167
Name:BALDWIN, JONATHAN E (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:E
Last Name:BALDWIN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2701 17TH ST
Mailing Address - Street 2:
Mailing Address - City:ROCK ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:61201-5351
Mailing Address - Country:US
Mailing Address - Phone:563-742-2054
Mailing Address - Fax:563-742-3505
Practice Address - Street 1:2701 17TH ST
Practice Address - Street 2:
Practice Address - City:ROCK ISLAND
Practice Address - State:IL
Practice Address - Zip Code:61201-5351
Practice Address - Country:US
Practice Address - Phone:563-742-2054
Practice Address - Fax:563-742-3505
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2018-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001737363A00000X
IL85002801363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
98263OtherBC WELLMARK
32117OtherBC WELLMARK
98269OtherBC WELLMARK
ILP00404317OtherRR MEDICARE
98263OtherBC WELLMARK
IAP00696079Medicare PIN
ILP00404317OtherRR MEDICARE
Q72261Medicare UPIN