Provider Demographics
NPI:1104212869
Name:BAKER, BENJAMIN JR
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:BAKER
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 CELEBRATE LIFE PKWY
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30265-8001
Mailing Address - Country:US
Mailing Address - Phone:770-400-6000
Mailing Address - Fax:
Practice Address - Street 1:600 CELEBRATE LIFE PKWY
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-8001
Practice Address - Country:US
Practice Address - Phone:770-400-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-09
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN202254363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health