Basic Information
| Provider Information | |||||||||
| NPI: | 1861493066 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALKER | ||||||||
| FirstName: | ALIA | ||||||||
| MiddleName: | MELISSA | ||||||||
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| Credential: | P.A.-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 111378 S 4757 RD | ||||||||
| Address2: | |||||||||
| City: | MULDROW | ||||||||
| State: | OK | ||||||||
| PostalCode: | 749487573 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 301 J T STITES BLVD | ||||||||
| Address2: | |||||||||
| City: | SALLISAW | ||||||||
| State: | OK | ||||||||
| PostalCode: | 749559302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9187759159 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2005 | ||||||||
| LastUpdateDate: | 04/17/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA889 | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 1600889 | 05 | OK | MEDICAID |