Provider Demographics
NPI:1295378313
Name:BAKER, ANTWAN LAJUNNE (AGACNP-BC)
Entity Type:Individual
Prefix:
First Name:ANTWAN
Middle Name:LAJUNNE
Last Name:BAKER
Suffix:
Gender:M
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:278 AMY CLEGG DR
Mailing Address - Street 2:
Mailing Address - City:GRAY
Mailing Address - State:GA
Mailing Address - Zip Code:31032-4747
Mailing Address - Country:US
Mailing Address - Phone:478-960-7232
Mailing Address - Fax:
Practice Address - Street 1:865 S 1ST ST
Practice Address - Street 2:
Practice Address - City:JESUP
Practice Address - State:GA
Practice Address - Zip Code:31545-0210
Practice Address - Country:US
Practice Address - Phone:912-427-6811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-21
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GANCO-000003364SA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2100XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAcute Care