Healthcare Provider Details

I. General information

NPI: 1114901519
Provider Name (Legal Business Name): ELIZABETH ANNE BAKER-AHLSTROM P.A.-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2005
Last Update Date: 03/31/2023
Certification Date: 03/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 NEWNAN CROSSING BYPASS SUITE A
NEWNAN GA
30263-2321
US

IV. Provider business mailing address

7300 RANCH ROAD 2222, BUILDING 1, STE 200
AUSTIN TX
78730
US

V. Phone/Fax

Practice location:
  • Phone: 770-251-5111
  • Fax: 770-254-8680
Mailing address:
  • Phone: 512-628-0465
  • Fax: 512-233-2711

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number003574
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: