=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427285949
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROXANA REYNAFARJE BAXTER MSPA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/11/2009
-----------------------------------------------------
Last Update Date | 10/26/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 23823 EL TORO RD STE E122
-----------------------------------------------------
City | LAKE FOREST
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92630-4743
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-380-1227
-----------------------------------------------------
Fax | 949-380-1759
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 23823 EL TORO RD STE E122
-----------------------------------------------------
City | LAKE FOREST
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92630-4743
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-380-1227
-----------------------------------------------------
Fax | 949-380-1759
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | PA16702
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------