Basic Information
| Provider Information | |||||||||
| NPI: | 1376644930 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALSH | ||||||||
| FirstName: | CHRISTINE | ||||||||
| MiddleName: | CHOUTEAU | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2029 GORDON COOPER DR | ||||||||
| Address2: | |||||||||
| City: | SHAWNEE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 748019005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4058784702 | ||||||||
| FaxNumber: | 4052144227 | ||||||||
| Practice Location | |||||||||
| Address1: | 2029 GORDON COOPER DR | ||||||||
| Address2: | |||||||||
| City: | SHAWNEE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 748019005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4058784702 | ||||||||
| FaxNumber: | 4052144227 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2006 | ||||||||
| LastUpdateDate: | 04/04/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 23689 | OK | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1123689 | 05 | OK | MEDICAID |