Provider Demographics
NPI:1235469925
Name:WALTER, DEREK WALLACE (PTA)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:WALLACE
Last Name:WALTER
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1603 COURT ST
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13208-1834
Mailing Address - Country:US
Mailing Address - Phone:315-455-7591
Mailing Address - Fax:
Practice Address - Street 1:1603 COURT ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13208-1834
Practice Address - Country:US
Practice Address - Phone:315-455-7591
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-04
Last Update Date:2010-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant