Healthcare Provider Details

I. General information

NPI: 1356349914
Provider Name (Legal Business Name): MATTHEW G BAKER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2005
Last Update Date: 06/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 E WT HARRIS BLVD SUITE 5202
CHARLOTTE NC
28262-3485
US

IV. Provider business mailing address

101 E WT HARRIS BLVD SUITE 5202
CHARLOTTE NC
28262-3485
US

V. Phone/Fax

Practice location:
  • Phone: 704-547-1495
  • Fax: 704-547-1861
Mailing address:
  • Phone: 704-547-1495
  • Fax: 704-547-1861

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0010-03915
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: