Provider Demographics
NPI:1457843310
Name:BAUMGARDNER, JAY DOUGLAS (PT, DPT)
Entity Type:Individual
Prefix:MR
First Name:JAY
Middle Name:DOUGLAS
Last Name:BAUMGARDNER
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17233 N HOLMES BLVD STE 1650
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85053-2031
Mailing Address - Country:US
Mailing Address - Phone:480-491-3563
Mailing Address - Fax:480-491-3572
Practice Address - Street 1:1941 W. GUADALUPE RD. SUITE 109
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85202
Practice Address - Country:US
Practice Address - Phone:480-491-3563
Practice Address - Fax:480-491-3572
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-05
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ13657225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist