Basic Information
| Provider Information | |||||||||
| NPI: | 1568430015 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALKER | ||||||||
| FirstName: | BRETT | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 315 MARTIN LUTHER KING JR WAY | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984054234 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2534031000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 315 MARTIN LUTHER KING JR WAY | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984054234 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2534031000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2006 | ||||||||
| LastUpdateDate: | 08/31/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QS0010X | 036-106890 | IL | N | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 207Q00000X | 45575 | CO | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 42695-020 | WI | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | MD60577630 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036106890 | 05 | IL | MEDICAID |