Provider Demographics
NPI:1922590181
Name:BAXTER, CODY M
Entity Type:Individual
Prefix:
First Name:CODY
Middle Name:M
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 1:3625 LINCOLN ST S STE C
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-7766
Mailing Address - Country:US
Mailing Address - Phone:701-532-2458
Mailing Address - Fax:701-935-7277
Practice Address - Street 1:3625 LINCOLN ST S STE C
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-7766
Practice Address - Country:US
Practice Address - Phone:701-532-2458
Practice Address - Fax:701-935-7277
Is Sole Proprietor?:No
Enumeration Date:2018-06-04
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant