Provider Demographics
NPI:1477632321
Name:WALTER, SALLY JO (LSA)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:JO
Last Name:WALTER
Suffix:
Gender:F
Credentials:LSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 S LAKELINE BLVD
Mailing Address - Street 2:SUITE 405
Mailing Address - City:CEDAR PARK
Mailing Address - State:TX
Mailing Address - Zip Code:78613-2718
Mailing Address - Country:US
Mailing Address - Phone:512-381-4272
Mailing Address - Fax:512-381-4275
Practice Address - Street 1:201 S LAKELINE BLVD
Practice Address - Street 2:SUITE 405
Practice Address - City:CEDAR PARK
Practice Address - State:TX
Practice Address - Zip Code:78613-2718
Practice Address - Country:US
Practice Address - Phone:512-381-4272
Practice Address - Fax:512-381-4275
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2014-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXSA00311246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant