Provider Demographics
NPI:1144480294
Name:WALTERS, JOHN SEXTON (LAC)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:SEXTON
Last Name:WALTERS
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7800 METRO PKWY
Mailing Address - Street 2:SUITE 300
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-1514
Mailing Address - Country:US
Mailing Address - Phone:952-767-4910
Mailing Address - Fax:952-851-9618
Practice Address - Street 1:7800 METRO PKWY
Practice Address - Street 2:SUITE 300
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55425-1514
Practice Address - Country:US
Practice Address - Phone:952-767-4910
Practice Address - Fax:952-851-9618
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-12
Last Update Date:2015-11-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN1343171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN0000378093Medicaid