Healthcare Provider Details

I. General information

NPI: 1518957133
Provider Name (Legal Business Name): CRYSTAL L WALTON PA C CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2005
Last Update Date: 01/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1136 JACKSON BLVD
RAPID CITY SD
57702-4335
US

IV. Provider business mailing address

1136 JACKSON BLVD
RAPID CITY SD
57702-4335
US

V. Phone/Fax

Practice location:
  • Phone: 605-721-7246
  • Fax: 605-341-4501
Mailing address:
  • Phone: 605-721-7246
  • Fax: 605-341-4501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0539
License Number StateSD
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number0539
License Number StateSD
# 3
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number0539
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: