Provider Demographics
NPI:1437903614
Name:WALKER, MARK J
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:J
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:PO BOX 782
Mailing Address - Street 2:
Mailing Address - City:PINE
Mailing Address - State:AZ
Mailing Address - Zip Code:85544-0782
Mailing Address - Country:US
Mailing Address - Phone:928-399-1567
Mailing Address - Fax:
Practice Address - Street 1:6282 W HARDSCRABBLE MESA RD
Practice Address - Street 2:
Practice Address - City:PINE
Practice Address - State:AZ
Practice Address - Zip Code:85544-5240
Practice Address - Country:US
Practice Address - Phone:928-399-1567
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-15
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ27398225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist