Provider Demographics
NPI:1366504102
Name:WALKER, LARRY DEAN (PA-C)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:DEAN
Last Name:WALKER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:935 HIGHLAND BLVD
Mailing Address - Street 2:SUITE 2210
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-6998
Mailing Address - Country:US
Mailing Address - Phone:406-587-3133
Mailing Address - Fax:406-586-9671
Practice Address - Street 1:935 HIGHLAND BLVD
Practice Address - Street 2:SUITE 2210
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-6998
Practice Address - Country:US
Practice Address - Phone:406-587-3133
Practice Address - Fax:406-586-9671
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2010-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT117363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1366504102Medicaid
MT011004083Medicare PIN