Basic Information
| Provider Information | |||||||||
| NPI: | 1639142508 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALKER | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1333 W 5TH ST, STE 110 | ||||||||
| Address2: | |||||||||
| City: | SHERIDAN | ||||||||
| State: | WY | ||||||||
| PostalCode: | 828012752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076752650 | ||||||||
| FaxNumber: | 3076752651 | ||||||||
| Practice Location | |||||||||
| Address1: | 1333 W 5TH ST, STE 112 | ||||||||
| Address2: | |||||||||
| City: | SHERIDAN | ||||||||
| State: | WY | ||||||||
| PostalCode: | 828012752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076752650 | ||||||||
| FaxNumber: | 3076752651 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2006 | ||||||||
| LastUpdateDate: | 05/11/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 4231 | SD | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | TL2282 | WY | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 6003370 | 05 | SD | MEDICAID |