Provider Demographics
NPI:1023032513
Name:WOLF, WALTER (PTA, PES, CES)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:
Last Name:WOLF
Suffix:
Gender:M
Credentials:PTA, PES, CES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5111 S REGAL ST APT 3
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99223-9102
Mailing Address - Country:US
Mailing Address - Phone:509-590-8485
Mailing Address - Fax:
Practice Address - Street 1:1132 E POLSTON AVE
Practice Address - Street 2:
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-6045
Practice Address - Country:US
Practice Address - Phone:208-777-7800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2014-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
WAP160049952225200000X
IDPTA-2416225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer