Provider Demographics
NPI:1255789392
Name:BAKER, MATTHEW TSAMPICO (PA-C)
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:TSAMPICO
Last Name:BAKER
Suffix:
Gender:M
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 1:807 STATE ROAD 44
Mailing Address - Street 2:
Mailing Address - City:NEW SMYRNA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32168-7271
Mailing Address - Country:US
Mailing Address - Phone:386-428-5554
Mailing Address - Fax:386-428-6291
Practice Address - Street 1:807 STATE ROAD 44
Practice Address - Street 2:
Practice Address - City:NEW SMYRNA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32168-7271
Practice Address - Country:US
Practice Address - Phone:386-428-5554
Practice Address - Fax:386-428-6291
Is Sole Proprietor?:No
Enumeration Date:2016-05-31
Last Update Date:2016-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPAX000012566363A00000X
FLPA9109462363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical