Provider Demographics
NPI:1871024117
Name:BAUER, JESSE BLAKE
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:BLAKE
Last Name:BAUER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JESSE
Other - Middle Name:BLAKE
Other - Last Name:COGBURN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1607 SAINT JAMES CT STE 1
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-5352
Mailing Address - Country:US
Mailing Address - Phone:850-431-7021
Mailing Address - Fax:
Practice Address - Street 1:1300 MICCOSUKEE RD
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-5054
Practice Address - Country:US
Practice Address - Phone:850-431-0911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-27
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME145248207P00000X
390200000X
NC227135207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program