Provider Demographics
NPI:1457350258
Name:BALTZELL, JONATHAN ROBERT (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:ROBERT
Last Name:BALTZELL
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:PO BOX 602478
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2478
Mailing Address - Country:US
Mailing Address - Phone:704-801-2000
Mailing Address - Fax:704-801-2001
Practice Address - Street 1:10210 COULOAK DR
Practice Address - Street 2:SUITE E
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28216-7679
Practice Address - Country:US
Practice Address - Phone:704-801-2000
Practice Address - Fax:704-801-2001
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2014-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC102359363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1457350258Medicaid
NC2747011COtherMEDICARE PTAN
NC8101948Medicaid
NCNC6291MMedicare PIN
NCNC6291CMedicare PIN
NCNC6291DMedicare PIN
NCNC6291NMedicare PIN
NC2747011BMedicare PIN
NC1457350258Medicaid
NCNC6291FMedicare PIN
NCNC6291KMedicare PIN
NCNC6291GMedicare PIN
NCNC6291HMedicare PIN
NCNC6291AMedicare PIN
NC2747011COtherMEDICARE PTAN
NCNC6291EMedicare PIN
NCNC6291LMedicare PIN
NCNC6291OMedicare PIN
NCNC6291BMedicare PIN
NC8101948Medicaid
SCS69315Medicare PIN