Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 152W00000X | Optometrist | 704 | AZ |
NPI | 1003889460 |
---|---|
Provider Name | Bradley J Walker |
First Address | Mesa, AZ 85213-8436 |
Second Address | Safford, AZ 85546-4081 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/02/2006 |
Last Update Date | 17/10/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
T77002 | (02) | AZ |