Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 204C00000X | Sports Medicine Doctor | M6243 | ID |
NPI | 1134135775 |
---|---|
Provider Name | Dr. Gary C Walker |
First Address | Idaho Falls, ID 83404-7407 |
Second Address | Idaho Falls, ID 83404-7407 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/08/2006 |
Last Update Date | 14/11/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
003994100 | (05) | ID |
204221200 | US DEPT OF LABOR (01) | ID |
E65389 | (02) | ID |