Healthcare Provider Details

I. General information

NPI: 1568599215
Provider Name (Legal Business Name): TYLER MITCHELL BAXTER DPT, OCS, ATC, CSCS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2007
Last Update Date: 03/11/2025
Certification Date: 03/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1812 N LAKEWOOD DR STE 100
COEUR D ALENE ID
83814-2635
US

IV. Provider business mailing address

850 W IRONWOOD DR STE 202
COEUR D ALENE ID
83814-4903
US

V. Phone/Fax

Practice location:
  • Phone: 208-966-4476
  • Fax: 208-966-4475
Mailing address:
  • Phone: 208-664-2175
  • Fax: 208-664-1226

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT-2565
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: