Provider Demographics
NPI:1497985139
Name:BAKER, COURTNEY TALLEY (PA-C)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:TALLEY
Last Name:BAKER
Suffix:
Gender:F
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 1:1100 E WENDOVER AVE
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27405-6713
Mailing Address - Country:US
Mailing Address - Phone:336-641-7777
Mailing Address - Fax:
Practice Address - Street 1:1100 E WENDOVER AVE
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27405-6713
Practice Address - Country:US
Practice Address - Phone:336-641-7777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-15
Last Update Date:2014-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-02583363A00000X, 363AM0700X
VA0110003059363A00000X
VA011003059363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical