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General NPI Number Information
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NPI Number | 1104293158
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Entity Type | Individual
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Provider Name | WYATT DALE BAXTER PA-C
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Gender | Male
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Dates
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Enumeration Date | 08/25/2015
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Last Update Date | 08/25/2015
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Provider Practice Location Address
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Address Line | 1221 S GEAR AVE
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City | WEST BURLINGTON
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State | IA
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Zip | 52655-1679
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Country | US
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Telephone | 319-768-1000
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Fax |
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Provider Business Mailing Address
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Address Line | 1393 N COUNTY ROAD 3000
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City | TENNESSEE
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State | IL
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Zip | 62374-3037
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 079496
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License Number State | IA
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