Provider Demographics
NPI:1003831249
Name:WALKER, MATTHEW LYLE (MPT)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:LYLE
Last Name:WALKER
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2321 E GALA ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-4881
Mailing Address - Country:US
Mailing Address - Phone:208-888-4321
Mailing Address - Fax:208-895-8747
Practice Address - Street 1:2321 E GALA ST
Practice Address - Street 2:SUITE 1
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-4881
Practice Address - Country:US
Practice Address - Phone:208-888-4321
Practice Address - Fax:208-895-8747
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT1718225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010148919OtherREGENCE
IDTA914OtherBLUE CROSS OF IDAHO PROV
ID1654879Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER