Healthcare Provider Details

I. General information

NPI: 1184692410
Provider Name (Legal Business Name): DIAN M WALSTON PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2006
Last Update Date: 10/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1510 S VIRGINIA AVE
ATOKA OK
74525-3246
US

IV. Provider business mailing address

1510 S VIRGINIA AVE
ATOKA OK
74525-3246
US

V. Phone/Fax

Practice location:
  • Phone: 580-889-6621
  • Fax: 580-889-6659
Mailing address:
  • Phone: 580-889-6621
  • Fax: 580-889-6659

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1229
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: