Provider Demographics
NPI:1376727636
Name:WALKER, BRIAN
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:
Last Name:WALKER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:465 41ST AVE NE
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33703-5003
Mailing Address - Country:US
Mailing Address - Phone:727-366-6512
Mailing Address - Fax:
Practice Address - Street 1:465 41ST AVE NE
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33703-5003
Practice Address - Country:US
Practice Address - Phone:727-366-6512
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-21
Last Update Date:2007-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA17514225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist