Provider Demographics
NPI:1275612590
Name:WALRATH, JAMES ALFRED (DPT)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:ALFRED
Last Name:WALRATH
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4200 SUNRISE HWY
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758-5303
Mailing Address - Country:US
Mailing Address - Phone:516-541-1064
Mailing Address - Fax:516-798-9070
Practice Address - Street 1:4200 SUNRISE HWY
Practice Address - Street 2:
Practice Address - City:MASSAPEQUA
Practice Address - State:NY
Practice Address - Zip Code:11758-5303
Practice Address - Country:US
Practice Address - Phone:516-541-1064
Practice Address - Fax:516-798-9070
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026593-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ11S11Medicare ID - Type UnspecifiedMEDICARE