Provider Demographics
NPI:1346508363
Name:BAUMGARTNER, SHAVONDA
Entity Type:Individual
Prefix:MS
First Name:SHAVONDA
Middle Name:
Last Name:BAUMGARTNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHAVONDA
Other - Middle Name:
Other - Last Name:THOMAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:844-266-8268
Mailing Address - Fax:
Practice Address - Street 1:8401 MEDICAL PLAZA DR STE 250
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262
Practice Address - Country:US
Practice Address - Phone:704-384-1500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-27
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN562312083P0901X, 207R00000X
NC2015-01471207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN56231OtherSTATE OF TENNESSEE MEDICAL LICENSE