1790749521 NPI number — LARAINE F WALKER PHD, LP

Table of content: LARAINE F WALKER PHD, LP (NPI 1790749521)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790749521 NPI number — LARAINE F WALKER PHD, LP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALKER
Provider First Name:
LARAINE
Provider Middle Name:
F
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHD, LP
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:
1790749521
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 43
Provider Second Line Business Mailing Address:
MR 10809
Provider Business Mailing Address City Name:
MINNEAPOLIS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55440-0043
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-262-4813
Provider Business Mailing Address Fax Number:
612-262-4194

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1210 1ST ST W
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HASTINGS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55033-1147
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-438-1800
Provider Business Practice Location Address Fax Number:
651-438-1894
Provider Enumeration Date:
04/17/2006

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: 101YM0800X , with the licence number:  LP1306 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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