Provider Demographics
NPI:1265983555
Name:BAXTER, EDWIN (LMP)
Entity type:Individual
Prefix:
First Name:EDWIN
Middle Name:
Last Name:BAXTER
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3508 N ST
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98663-2440
Mailing Address - Country:US
Mailing Address - Phone:360-852-7424
Mailing Address - Fax:
Practice Address - Street 1:14313 NE 20TH AVE
Practice Address - Street 2:A112
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98686-1487
Practice Address - Country:US
Practice Address - Phone:360-574-9440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-21
Last Update Date:2016-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60690259225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist