Provider Demographics
NPI:1508461856
Name:WALKUP FAMILY MEDICINE CLINIC LLC
Entity Type:Organization
Organization Name:WALKUP FAMILY MEDICINE CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STORMY
Authorized Official - Middle Name:
Authorized Official - Last Name:WALKUP
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:405-639-7771
Mailing Address - Street 1:1302 S LYNN LN
Mailing Address - Street 2:
Mailing Address - City:IDABEL
Mailing Address - State:OK
Mailing Address - Zip Code:74745-6860
Mailing Address - Country:US
Mailing Address - Phone:580-286-3993
Mailing Address - Fax:580-286-3967
Practice Address - Street 1:1302 S LYNN LN
Practice Address - Street 2:
Practice Address - City:IDABEL
Practice Address - State:OK
Practice Address - Zip Code:74745-6860
Practice Address - Country:US
Practice Address - Phone:405-639-7771
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-03
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200730970AMedicaid