Healthcare Provider Details

I. General information

NPI: 1023032513
Provider Name (Legal Business Name): WALTER WOLF PTA, PES, CES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 08/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1132 E POLSTON AVE
POST FALLS ID
83854-6045
US

IV. Provider business mailing address

5111 S REGAL ST APT 3
SPOKANE WA
99223-9102
US

V. Phone/Fax

Practice location:
  • Phone: 208-777-7800
  • Fax:
Mailing address:
  • Phone: 509-590-8485
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberP160049952
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA-2416
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: