Healthcare Provider Details

I. General information

NPI: 1427049717
Provider Name (Legal Business Name): NESTOR ANTONIO BALDIZON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2005
Last Update Date: 06/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

148 CLINIC AVE
CARROLLTON GA
30117-4414
US

IV. Provider business mailing address

119 AMBULANCE DR SUITE 202
CARROLLTON GA
30117-3857
US

V. Phone/Fax

Practice location:
  • Phone: 770-838-8640
  • Fax: 770-838-8650
Mailing address:
  • Phone: 770-838-8640
  • Fax: 770-838-8650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number004239
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: