Provider Demographics
NPI:1104293158
Name:BAXTER, WYATT DALE (PA-C)
Entity type:Individual
Prefix:MR
First Name:WYATT
Middle Name:DALE
Last Name:BAXTER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1393 N COUNTY ROAD 3000
Mailing Address - Street 2:
Mailing Address - City:TENNESSEE
Mailing Address - State:IL
Mailing Address - Zip Code:62374-3037
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1221 S GEAR AVE
Practice Address - Street 2:
Practice Address - City:WEST BURLINGTON
Practice Address - State:IA
Practice Address - Zip Code:52655-1679
Practice Address - Country:US
Practice Address - Phone:319-768-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-25
Last Update Date:2015-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA079496363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant