Provider Demographics
NPI:1790856797
Name:BAUMGARDNER, JUDY M (MS PT)
Entity Type:Individual
Prefix:MRS
First Name:JUDY
Middle Name:M
Last Name:BAUMGARDNER
Suffix:
Gender:F
Credentials:MS PT
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1612
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83403-1612
Mailing Address - Country:US
Mailing Address - Phone:208-525-2090
Mailing Address - Fax:208-525-2662
Practice Address - Street 1:500 SKI HILL
Practice Address - Street 2:
Practice Address - City:DRIGGS
Practice Address - State:ID
Practice Address - Zip Code:83422
Practice Address - Country:US
Practice Address - Phone:208-354-3128
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2018-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-350225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807140300Medicaid