Provider Demographics
NPI:1831157767
Name:BAXTER, FELICIA
Entity type:Individual
Prefix:
First Name:FELICIA
Middle Name:
Last Name:BAXTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6025 BLAKENEY PARK DRIVE
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6025 BLAKENEY PARK DR
Practice Address - Street 2:SUITE 100
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-5703
Practice Address - Country:US
Practice Address - Phone:704-667-4480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2018-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200001464208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1831157767Medicaid
NC891351VMedicaid
SC302648Medicaid
NCNC6617AMedicare PIN
SC302648Medicaid
NC1831157767Medicaid
NCNC6617CMedicare PIN