MEDICARE: WALTER NICHOLAS ELLIS DPM

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	213E00000X	Podiatrist	451	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1588625958
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WALTER NICHOLAS ELLIS DPM

Provider Business Mailing Address
First Line	:	106 DOCTORS PARK
Second Line	:
City	:	ST CLOUD
State	:	MN
Zip	:	56303-1207
Country	:	US
Telephone Number	:	320-251-5444
Fax Number	:	320-656-9590

Provider Business Practice Location Address
First Line	:	106 DOCTORS PARK
Second Line	:
City	:	ST CLOUD
State	:	MN
Zip	:	56303-1207
Country	:	US
Telephone Number	:	320-251-5444
Fax Number	:	320-656-9590

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

Provider Enumeration Date	:	03/28/2006
Last Update Date	:	01/08/2015

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