1043629900 NPI number — WALKER DYER APRN

Table of content: WALKER DYER APRN (NPI 1043629900)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043629900 NPI number — WALKER DYER APRN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DYER
Provider First Name:
WALKER
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
APRN
Provider Gender Code:
M

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:
1043629900
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/10/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2158 BUTTERFIELD COACH RD
Provider Second Line Business Mailing Address:
STE 100
Provider Business Mailing Address City Name:
SPRINGDALE
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72764-9142
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-757-5023
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2000 S 42ND ST
Provider Second Line Business Practice Location Address:
STE 100
Provider Business Practice Location Address City Name:
ROGERS
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72758-2001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-273-9173
Provider Business Practice Location Address Fax Number:
479-464-9989
Provider Enumeration Date:
08/05/2014

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: 363LF0000X , with the licence number:  A004161 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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