Healthcare Provider Details

I. General information

NPI: 1386818805
Provider Name (Legal Business Name): WALTER JOHN AUSTIN C. PED
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2008
Last Update Date: 04/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4261 LIEN RD SUITE O
MADISON WI
53704-3689
US

IV. Provider business mailing address

4261 LIEN RD SUITE O
MADISON WI
53704-3689
US

V. Phone/Fax

Practice location:
  • Phone: 608-242-9273
  • Fax:
Mailing address:
  • Phone: 608-242-9273
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: