Individual
MR. JONATHAN ROBERT BALTZELL
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
10210 COULOAK DR, SUITE E, CHARLOTTE, NC 28216-7679
(704) 801-2000
(704) 801-2001
Mailing address
PO BOX 602478, CHARLOTTE, NC 28260-2478
(704) 801-2000
(704) 801-2001
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
102359
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1457350258
—
NC
01
—
2747011C
MEDICARE PTAN
NC
05
—
8101948
—
NC
Enumeration date
07/14/2005
Last updated
04/01/2014
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