=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114210614
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARSHALL WALKER LPN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/17/2011
-----------------------------------------------------
Last Update Date | 05/17/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 61 RUSTIC ST
-----------------------------------------------------
City | ROCHESTER
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14609-3509
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-284-0330
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 61 RUSTIC ST
-----------------------------------------------------
City | ROCHESTER
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14609-3509
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-284-0330
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 164W00000X
-----------------------------------------------------
Taxonomy Name | Licensed Practical Nurse
-----------------------------------------------------
License Number | 263771-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------