Basic Information
| Provider Information | |||||||||
| NPI: | 1235604042 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DESPLAS | ||||||||
| FirstName: | WALTON | ||||||||
| MiddleName: | MATTHEW | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 301 DUBLIN DR | ||||||||
| Address2: | |||||||||
| City: | RICHARDSON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750805840 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6825590288 | ||||||||
| FaxNumber: | 9723831061 | ||||||||
| Practice Location | |||||||||
| Address1: | 7777 FOREST LN STE B122 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752306806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9723831060 | ||||||||
| FaxNumber: | 9723831061 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/08/2018 | ||||||||
| LastUpdateDate: | 10/08/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WI0600X | RN79257 | NV | N | Nursing Service Providers | Registered Nurse | Infection Control | 163WI0600X | 794082 | TX | Y | Nursing Service Providers | Registered Nurse | Infection Control |
No ID Information.