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General NPI Number Information
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NPI Number | 1144284449
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Entity Type | Individual
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Provider Name | NICHOLAS RYAN WALTERS PA-C
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Gender | Male
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Dates
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Enumeration Date | 04/13/2006
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Last Update Date | 02/20/2015
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Provider Practice Location Address
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Address Line | 7600 W COLLEGE DR
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City | PALOS HEIGHTS
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State | IL
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Zip | 60463-1001
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Country | US
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Telephone | 708-361-0600
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Fax |
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Provider Business Mailing Address
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Address Line | 510 W ELLE ST
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City | ROMEOVILLE
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State | IL
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Zip | 60446-5295
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Country | US
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Telephone | 630-723-8699
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 096-002105
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 085.004177
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License Number State | IL
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