Provider Demographics
NPI:1013262393
Name:BAKER, JORDAN RENEE (PA)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:RENEE
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 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12016 LEMMOND FARM DR
Practice Address - Street 2:STE 100
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28227-8353
Practice Address - Country:US
Practice Address - Phone:704-863-9615
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-23
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-03625363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8102616Medicaid
SC2383PAMedicaid
NCNC7937MMedicare PIN
SC2383PAMedicaid
NCNC7937EMedicare PIN
NCNC7937AMedicare PIN
NCNC7937CMedicare PIN
NCNC7937DMedicare PIN
NCNC7937BMedicare PIN
NCNC7937KMedicare PIN
NCNC7937HMedicare PIN
NC8102616Medicaid
NCNC7937LMedicare PIN
NCNC7937FMedicare PIN
NCNC7937OMedicare PIN
NCNC7937JMedicare PIN