Provider Demographics
NPI:1689209322
Name:BAUMGARDNER, BENJAMIN ROBERT (DPT)
Entity Type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:ROBERT
Last Name:BAUMGARDNER
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 MARK WEST SPRINGS RD STE 300
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-1783
Mailing Address - Country:US
Mailing Address - Phone:707-367-8831
Mailing Address - Fax:
Practice Address - Street 1:5524 MARIT DR
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95409-3829
Practice Address - Country:US
Practice Address - Phone:707-367-8831
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-03
Last Update Date:2020-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
292519225100000X
CA292519225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist