MEDICARE: MRS. CRYSTAL L WALTON PA C CNP

Medicare Provider Information

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208100000X	Physical Medicine & Rehabilitation Physician	0539	SD
2	208VP0014X	Interventional Pain Medicine Physician	0539	SD
3	363A00000X	Physician Assistant	0539	SD

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	0122934	OTHER	SD	MEDICA
3	31781	OTHER	SD	SANFORD HEALTH PLAN
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	0539	OTHER	SD	DAKOTACARE
6	4995927	OTHER	SD	WELLMARK BCBS
7	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

NPI Number	:	1518957133
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CRYSTAL L WALTON PA C CNP

Provider Business Mailing Address
First Line	:	1136 JACKSON BLVD
Second Line	:
City	:	RAPID CITY
State	:	SD
Zip	:	57702-4335
Country	:	US
Telephone Number	:	605-721-7246
Fax Number	:	605-341-4501

Provider Business Practice Location Address
First Line	:	1136 JACKSON BLVD
Second Line	:
City	:	RAPID CITY
State	:	SD
Zip	:	57702-4335
Country	:	US
Telephone Number	:	605-721-7246
Fax Number	:	605-341-4501

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/25/2005
Last Update Date	:	01/10/2011

1136 JACKSON BLVD
RAPID CITY, SD
57702-4335

Practice Phone: 605-721-7246
Practice Fax: 605-341-4501