Healthcare Provider Details

I. General information

NPI: 1467925636
Provider Name (Legal Business Name): THOMAS R WALKER PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2019
Last Update Date: 01/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1928 SW 25TH ST
GRESHAM OR
97080-9523
US

IV. Provider business mailing address

1928 SW 25TH ST
GRESHAM OR
97080-9523
US

V. Phone/Fax

Practice location:
  • Phone: 503-679-6608
  • Fax:
Mailing address:
  • Phone: 503-679-6608
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number07248
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: