Basic Information
| Provider Information | |||||||||
| NPI: | 1568599215 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BAXTER | ||||||||
| FirstName: | TYLER | ||||||||
| MiddleName: | MITCHELL | ||||||||
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| Credential: | DPT, OCS, ATC, CSCS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 850 W IRONWOOD DR | ||||||||
| Address2: | STE 202 | ||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838144903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086642175 | ||||||||
| FaxNumber: | 2086641226 | ||||||||
| Practice Location | |||||||||
| Address1: | 1812 N LAKEWOOD DR STE 100 | ||||||||
| Address2: | |||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838142635 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2089664476 | ||||||||
| FaxNumber: | 2089664475 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2007 | ||||||||
| LastUpdateDate: | 06/12/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer | 225100000X | PT-2565 | ID | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.