Provider Demographics
NPI:1700898574
Name:BAXTER, MARVIN (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MR
First Name:MARVIN
Middle Name:
Last Name:BAXTER
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:407 ADRIAN DR
Mailing Address - Street 2:
Mailing Address - City:GARNER
Mailing Address - State:NC
Mailing Address - Zip Code:27529-3501
Mailing Address - Country:US
Mailing Address - Phone:919-773-1226
Mailing Address - Fax:
Practice Address - Street 1:201 STEVENS MILL RD
Practice Address - Street 2:
Practice Address - City:GOLDSBORO
Practice Address - State:NC
Practice Address - Zip Code:27530-1056
Practice Address - Country:US
Practice Address - Phone:919-731-3420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC102006363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant