=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093255150
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MIKE WALKER EMT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/08/2017
-----------------------------------------------------
Last Update Date | 03/08/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4501 W WESTCHESTER SQ
-----------------------------------------------------
City | WEST MILWAUKEE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53214-3642
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-595-1101
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4501 W WESTCHESTER SQ
-----------------------------------------------------
City | WEST MILWAUKEE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53214-3642
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 343900000X
-----------------------------------------------------
Taxonomy Name | Non-emergency Medical Transport (VAN)
-----------------------------------------------------
License Number | 70104095
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------