Provider Demographics
NPI:1427049717
Name:BALDIZON, NESTOR ANTONIO (PA-C)
Entity type:Individual
Prefix:MR
First Name:NESTOR
Middle Name:ANTONIO
Last Name:BALDIZON
Suffix:
Gender:M
Credentials:PA-C
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Mailing Address - Street 1:119 AMBULANCE DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-3857
Mailing Address - Country:US
Mailing Address - Phone:770-838-8640
Mailing Address - Fax:770-838-8650
Practice Address - Street 1:148 CLINIC AVE
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-4414
Practice Address - Country:US
Practice Address - Phone:770-838-8640
Practice Address - Fax:770-838-8650
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2014-06-30
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA004239363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA253274100BMedicaid