Healthcare Provider Details

I. General information

NPI: 1326888348
Provider Name (Legal Business Name): DR. KEVIN WALP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/28/2024
Last Update Date: 08/14/2024
Certification Date: 08/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

224 W D. L. INGRAM AVENUE, BLDG. 1408
CANNON AFB NM
88103
US

IV. Provider business mailing address

710 SASHA LN
TAHLEQUAH OK
74464-6202
US

V. Phone/Fax

Practice location:
  • Phone: 316-258-0733
  • Fax:
Mailing address:
  • Phone: 316-258-0733
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3281
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: