Healthcare Provider Details

I. General information

NPI: 1164189080
Provider Name (Legal Business Name): DUSTYN SLADE LEE WALTON PT, DPT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/27/2021
Last Update Date: 01/30/2025
Certification Date: 01/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

921 S 8TH AVE
POCATELLO ID
83209-0002
US

IV. Provider business mailing address

921 S 8TH AVE STOP 8619 APT. I1
POCATELLO ID
83209
US

V. Phone/Fax

Practice location:
  • Phone: 307-696-5885
  • Fax:
Mailing address:
  • Phone: 307-696-5885
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberLAT-5681
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: