Provider Demographics
NPI:1740150234
Name:BAUMGARDT, COOPER
Entity type:Individual
Prefix:
First Name:COOPER
Middle Name:
Last Name:BAUMGARDT
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 1:419 22ND AVE
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-3812
Mailing Address - Country:US
Mailing Address - Phone:208-816-6078
Mailing Address - Fax:
Practice Address - Street 1:419 22ND AVE
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-3812
Practice Address - Country:US
Practice Address - Phone:208-816-6078
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-11-10
Last Update Date:2025-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation PractitionerGroup - Single Specialty