1679891907 NPI number — PATRICK ROGER WALTER PA

Table of content: PATRICK ROGER WALTER PA (NPI 1679891907)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679891907 NPI number — PATRICK ROGER WALTER PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALTER
Provider First Name:
PATRICK
Provider Middle Name:
ROGER
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
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:
1679891907
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/25/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8171 31ST ST SE UNIT 6
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JAMESTOWN
Provider Business Mailing Address State Name:
ND
Provider Business Mailing Address Postal Code:
58401-9258
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
701-252-7067
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
904 5TH AVE NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JAMESTOWN
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58401-3437
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-253-4020
Provider Business Practice Location Address Fax Number:
701-253-4040
Provider Enumeration Date:
05/11/2010

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: 363AS0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 71138 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".




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