Provider Demographics
NPI:1760109912
Name:BAXTER, RYAN
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:BAXTER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6451 SKYLARK DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-8549
Mailing Address - Country:US
Mailing Address - Phone:517-395-9584
Mailing Address - Fax:
Practice Address - Street 1:11301 BROOKLYN RD
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:MI
Practice Address - Zip Code:49230-8485
Practice Address - Country:US
Practice Address - Phone:517-592-2475
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-27
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program