Provider Demographics
NPI:1568599215
Name:BAXTER, TYLER MITCHELL (DPT, OCS, ATC, CSCS)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:MITCHELL
Last Name:BAXTER
Suffix:
Gender:M
Credentials:DPT, OCS, ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 W IRONWOOD DR
Mailing Address - Street 2:STE 202
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-4903
Mailing Address - Country:US
Mailing Address - Phone:208-664-2175
Mailing Address - Fax:208-664-1226
Practice Address - Street 1:1812 N LAKEWOOD DR STE 100
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2635
Practice Address - Country:US
Practice Address - Phone:208-966-4476
Practice Address - Fax:208-966-4475
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2020-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
IDPT-2565225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
1652809Medicare PIN