MEDICARE: GLORIA D WALZ CNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	0270	SD

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	970015058	OTHER		MEDICARE RAILROAD PTAN

General Provider Information

NPI Number	:	1326028937
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GLORIA D WALZ CNP

Provider Business Mailing Address
First Line	:	353 FAIRMONT BLVD
Second Line	:	ATTEN MSS
City	:	RAPID CITY
State	:	SD
Zip	:	57701-7375
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1041 MONTGOMERY STREET
Second Line	:
City	:	CUSTER
State	:	SD
Zip	:	57730-1304
Country	:	US
Telephone Number	:	605-673-4150
Fax Number	:	605-673-3917

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/19/2006
Last Update Date	:	01/23/2013

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