Basic Information
| Provider Information | |||||||||
| NPI: | 1760145312 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALIN | ||||||||
| FirstName: | ANTHONY | ||||||||
| MiddleName: | WAYNE | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2895 N MYRTLE RD | ||||||||
| Address2: | |||||||||
| City: | MYRTLE CREEK | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974579660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6193005361 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2901 E BARNETT RD | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975048308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417794221 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2021 | ||||||||
| LastUpdateDate: | 10/25/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225500000X | 9881 | OR | N | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | 225200000X | 9881 | OR | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.