Provider Demographics
NPI:1164493474
Name:WALTERS, CRISTINE A (MPT)
Entity Type:Individual
Prefix:MS
First Name:CRISTINE
Middle Name:A
Last Name:WALTERS
Suffix:
Gender:F
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:PO BOX 553
Mailing Address - Street 2:
Mailing Address - City:ASHTON
Mailing Address - State:ID
Mailing Address - Zip Code:83420-0553
Mailing Address - Country:US
Mailing Address - Phone:208-313-3735
Mailing Address - Fax:208-372-0609
Practice Address - Street 1:512 MAIN ST
Practice Address - Street 2:
Practice Address - City:ASHTON
Practice Address - State:ID
Practice Address - Zip Code:83420-5026
Practice Address - Country:US
Practice Address - Phone:208-652-9979
Practice Address - Fax:208-372-0609
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-27
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDRPT-1604225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8069260Medicaid
IDT8802OtherBLUE CROSS
ID000010146459OtherREGENCE BLUE SHIELD
ID1655481Medicare ID - Type Unspecified