Basic Information
| Provider Information | |||||||||
| NPI: | 1427049717 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BALDIZON | ||||||||
| FirstName: | NESTOR | ||||||||
| MiddleName: | ANTONIO | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 119 AMBULANCE DR | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | CARROLLTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301173857 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708388640 | ||||||||
| FaxNumber: | 7708388650 | ||||||||
| Practice Location | |||||||||
| Address1: | 148 CLINIC AVE | ||||||||
| Address2: | |||||||||
| City: | CARROLLTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301174414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708388640 | ||||||||
| FaxNumber: | 7708388650 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2005 | ||||||||
| LastUpdateDate: | 06/30/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 004239 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 253274100B | 05 | GA | MEDICAID |