=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558508085
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BEAU G WALKER P.A.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/21/2009
-----------------------------------------------------
Last Update Date | 09/18/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 333 N 1ST ST SUITE 280
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83702-6100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-345-6545
-----------------------------------------------------
Fax | 208-345-1213
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 190 E BANNOCK ST
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83712-6241
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-345-6545
-----------------------------------------------------
Fax | 208-345-1213
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AS0400X
-----------------------------------------------------
Taxonomy Name | Surgical Physician Assistant
-----------------------------------------------------
License Number | PA-788
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------