Provider Demographics
NPI:1326028937
Name:WALZ, GLORIA D (CNP)
Entity Type:Individual
Prefix:
First Name:GLORIA
Middle Name:D
Last Name:WALZ
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:353 FAIRMONT BLVD
Mailing Address - Street 2:ATTEN MSS
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-7375
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1041 MONTGOMERY STREET
Practice Address - Street 2:
Practice Address - City:CUSTER
Practice Address - State:SD
Practice Address - Zip Code:57730-1304
Practice Address - Country:US
Practice Address - Phone:605-673-4150
Practice Address - Fax:605-673-3917
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2013-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0270363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
970015058OtherMEDICARE RAILROAD PTAN
SDS7053Medicare PIN
SDS06642Medicare UPIN