Provider Demographics
NPI:1194395392
Name:WALTHER, VIRGINIA JANETTE (PTA)
Entity Type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:JANETTE
Last Name:WALTHER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 MIDLAND AVE
Mailing Address - Street 2:
Mailing Address - City:EAST SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13057-2125
Mailing Address - Country:US
Mailing Address - Phone:443-523-2813
Mailing Address - Fax:
Practice Address - Street 1:4600 SOUTHWOOD HEIGHTS DR
Practice Address - Street 2:
Practice Address - City:JAMESVILLE
Practice Address - State:NY
Practice Address - Zip Code:13078-9595
Practice Address - Country:US
Practice Address - Phone:315-496-1300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-29
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012609-01225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant