Healthcare Provider Details

I. General information

NPI: 1770029449
Provider Name (Legal Business Name): BRIAN JAMES WALSTROM PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/18/2017
Last Update Date: 01/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8880 NE 82ND TER
KANSAS CITY MO
64158-1313
US

IV. Provider business mailing address

8880 NE 82ND TER
KANSAS CITY MO
64158-1313
US

V. Phone/Fax

Practice location:
  • Phone: 816-437-8122
  • Fax: 816-407-9609
Mailing address:
  • Phone: 816-437-8122
  • Fax: 816-407-9609

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2014037309
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: