Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207X00000X | Orthopaedic Surgeon | 60003 | MN |
N | 207XX0005X | Sports Medicine Orthopaedic Surgeon | 60003 | MN |
NPI | 1114241882 |
---|---|
Provider Name | Brian Lee Walters |
First Address | Maple Grove, MN 55369-4485 |
Second Address | Maple Grove, MN 55369 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/03/2010 |
Last Update Date | 17/12/2018 |