Healthcare Provider Details

I. General information

NPI: 1760145312
Provider Name (Legal Business Name): ANTHONY WAYNE WALIN PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2021
Last Update Date: 10/25/2021
Certification Date: 10/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2901 E BARNETT RD
MEDFORD OR
97504-8308
US

IV. Provider business mailing address

2895 N MYRTLE RD
MYRTLE CREEK OR
97457-9660
US

V. Phone/Fax

Practice location:
  • Phone: 541-779-4221
  • Fax:
Mailing address:
  • Phone: 619-300-5361
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225500000X
TaxonomyRespiratory/Developmental/Rehabilitative Specialist/Technologist
License Number9881
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number9881
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: