1750624714 NPI number — DR. ANDREA DANIELLE WALKER MD

Table of content: DR. ANDREA DANIELLE WALKER MD (NPI 1750624714)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750624714 NPI number — DR. ANDREA DANIELLE WALKER MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALKER
Provider First Name:
ANDREA
Provider Middle Name:
DANIELLE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1750624714
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/24/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2750 W NORTH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60647-5247
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
312-666-3494
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2200 W 21ST ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLOVIS
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88101
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-742-7894
Provider Business Practice Location Address Fax Number:
575-742-7856
Provider Enumeration Date:
03/28/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X , with the licence number:  036.162565 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 09402292 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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