Provider Demographics
NPI:1477597946
Name:BAKER, CHARLES (PHYSICIAN ASSISTANCE)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:BAKER
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANCE
Other - Prefix:
Other - First Name:CHARLES
Other - Middle Name:J
Other - Last Name:BAKER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHYSICIAN ASSISTANCE
Mailing Address - Street 1:334 SMITH AVE
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31792-5533
Mailing Address - Country:US
Mailing Address - Phone:229-227-1595
Mailing Address - Fax:229-227-1385
Practice Address - Street 1:334 SMITH AVE
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792-5533
Practice Address - Country:US
Practice Address - Phone:229-227-1595
Practice Address - Fax:229-227-1385
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-15
Last Update Date:2018-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003660363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA100001820PMedicaid
GA97WCGJLMedicare ID - Type Unspecified