Provider Demographics
NPI:1215943055
Name:BALDWIN, ATHENA BEVETTE (PA-C)
Entity type:Individual
Prefix:
First Name:ATHENA
Middle Name:BEVETTE
Last Name:BALDWIN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10185 ETHEL CT
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20111-2616
Mailing Address - Country:US
Mailing Address - Phone:503-828-6167
Mailing Address - Fax:
Practice Address - Street 1:882 GARRISONVILLE RD
Practice Address - Street 2:
Practice Address - City:STAFFORD
Practice Address - State:VA
Practice Address - Zip Code:22554-3907
Practice Address - Country:US
Practice Address - Phone:540-318-6464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110-006277363A00000X
COPA-2849363A00000X
TXPA04742363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8L8028Medicare PIN
TX8G8094Medicare PIN