Healthcare Provider Details

I. General information

NPI: 1376237941
Provider Name (Legal Business Name): CORRIE ALEXIS BAKER PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2023
Last Update Date: 09/13/2023
Certification Date: 09/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

980 JOHNSON FERRY RD STE 820
ATLANTA GA
30342-1608
US

IV. Provider business mailing address

980 JOHNSON FERRY RD STE 820
ATLANTA GA
30342-1608
US

V. Phone/Fax

Practice location:
  • Phone: 404-252-9307
  • Fax: 404-252-5839
Mailing address:
  • Phone: 404-252-9307
  • Fax: 404-252-5839

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number11805
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: