=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285024877
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MR. WALTER WARNER III
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/03/2015
-----------------------------------------------------
Last Update Date | 01/18/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1081 AURORA DR
-----------------------------------------------------
City | FAIRBANKS
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99709-5508
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-457-7759
-----------------------------------------------------
Fax | 907-457-7481
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1081 AURORA DR
-----------------------------------------------------
City | FAIRBANKS
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99709-5508
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-457-7759
-----------------------------------------------------
Fax | 907-457-7481
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 172V00000X
-----------------------------------------------------
Taxonomy Name | Community Health Worker
-----------------------------------------------------
License Number | 293586
-----------------------------------------------------
License Number State | AK
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 374U00000X
-----------------------------------------------------
Taxonomy Name | Home Health Aide
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------