Basic Information
| Provider Information | |||||||||
| NPI: | 1295378313 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BAKER | ||||||||
| FirstName: | ANTWAN | ||||||||
| MiddleName: | LAJUNNE | ||||||||
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| Credential: | AGACNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 278 AMY CLEGG DR | ||||||||
| Address2: | |||||||||
| City: | GRAY | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310324747 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4789607232 | ||||||||
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| Practice Location | |||||||||
| Address1: | 865 S 1ST ST | ||||||||
| Address2: | |||||||||
| City: | JESUP | ||||||||
| State: | GA | ||||||||
| PostalCode: | 315450210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9124276811 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/21/2019 | ||||||||
| LastUpdateDate: | 10/21/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 364SA2100X | NCO-000003 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Acute Care |
No ID Information.