MEDICARE: MR. JONATHAN ROBERT BALTZELL PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	102359	NC

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	2747011C	OTHER	NC	MEDICARE PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1457350258
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JONATHAN ROBERT BALTZELL PA-C

Provider Business Mailing Address
First Line	:	PO BOX 602478
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28260-2478
Country	:	US
Telephone Number	:	704-801-2000
Fax Number	:	704-801-2001

Provider Business Practice Location Address
First Line	:	10210 COULOAK DR
Second Line	:	SUITE E
City	:	CHARLOTTE
State	:	NC
Zip	:	28216-7679
Country	:	US
Telephone Number	:	704-801-2000
Fax Number	:	704-801-2001

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/14/2005
Last Update Date	:	04/01/2014

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