Provider Demographics
NPI:1407534316
Name:BALDWIN, DUSTIN KYLE
Entity type:Individual
Prefix:
First Name:DUSTIN
Middle Name:KYLE
Last Name:BALDWIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:590 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SNOWFLAKE
Mailing Address - State:AZ
Mailing Address - Zip Code:85937-5228
Mailing Address - Country:US
Mailing Address - Phone:928-536-7519
Mailing Address - Fax:928-532-2139
Practice Address - Street 1:590 S MAIN ST
Practice Address - Street 2:
Practice Address - City:SNOWFLAKE
Practice Address - State:AZ
Practice Address - Zip Code:85937-5228
Practice Address - Country:US
Practice Address - Phone:928-536-7519
Practice Address - Fax:928-532-2139
Is Sole Proprietor?:No
Enumeration Date:2023-07-10
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ294738363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily