1366504102 NPI number — LARRY DEAN WALKER PA-C

Table of content: LARRY DEAN WALKER PA-C (NPI 1366504102)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366504102 NPI number — LARRY DEAN WALKER PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALKER
Provider First Name:
LARRY
Provider Middle Name:
DEAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
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:
1366504102
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/17/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
935 HIGHLAND BLVD
Provider Second Line Business Mailing Address:
SUITE 2210
Provider Business Mailing Address City Name:
BOZEMAN
Provider Business Mailing Address State Name:
MT
Provider Business Mailing Address Postal Code:
59715-6998
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
406-587-3133
Provider Business Mailing Address Fax Number:
406-586-9671

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
935 HIGHLAND BLVD
Provider Second Line Business Practice Location Address:
SUITE 2210
Provider Business Practice Location Address City Name:
BOZEMAN
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59715-6998
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-587-3133
Provider Business Practice Location Address Fax Number:
406-586-9671
Provider Enumeration Date:
12/15/2006

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: 363AM0700X , with the licence number:  117 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1366504102 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com