Provider Demographics
NPI:1720604242
Name:BAUMGARDNER, LEWIS NATHAN (PT, DPT, CSCS)
Entity Type:Individual
Prefix:
First Name:LEWIS
Middle Name:NATHAN
Last Name:BAUMGARDNER
Suffix:
Gender:M
Credentials:PT, DPT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 S COUNTRY CLUB RD
Mailing Address - Street 2:
Mailing Address - City:EL RENO
Mailing Address - State:OK
Mailing Address - Zip Code:73036-5304
Mailing Address - Country:US
Mailing Address - Phone:405-422-1291
Mailing Address - Fax:
Practice Address - Street 1:1300 S COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:EL RENO
Practice Address - State:OK
Practice Address - Zip Code:73036-5304
Practice Address - Country:US
Practice Address - Phone:405-422-1291
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-20
Last Update Date:2020-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5840225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist