Provider Demographics
NPI:1558366807
Name:BAKER, BRANDY P (PA)
Entity Type:Individual
Prefix:
First Name:BRANDY
Middle Name:P
Last Name:BAKER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 421718
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:SC
Mailing Address - Zip Code:29442-4203
Mailing Address - Country:US
Mailing Address - Phone:843-652-8226
Mailing Address - Fax:
Practice Address - Street 1:1075 N FRASER ST
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:SC
Practice Address - Zip Code:29440-2848
Practice Address - Country:US
Practice Address - Phone:843-527-4442
Practice Address - Fax:843-527-4027
Is Sole Proprietor?:No
Enumeration Date:2005-06-14
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1155363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q45245Medicare UPIN