Provider Demographics
NPI:1518957133
Name:WALTON, CRYSTAL L (PA C CNP)
Entity Type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:L
Last Name:WALTON
Suffix:
Gender:F
Credentials:PA C CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1136 JACKSON BLVD
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702-4335
Mailing Address - Country:US
Mailing Address - Phone:605-721-7246
Mailing Address - Fax:605-341-4501
Practice Address - Street 1:1136 JACKSON BLVD
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57702-4335
Practice Address - Country:US
Practice Address - Phone:605-721-7246
Practice Address - Fax:605-341-4501
Is Sole Proprietor?:No
Enumeration Date:2005-10-25
Last Update Date:2011-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0539208100000X, 208VP0014X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD1518957133Medicaid
SD0122934OtherMEDICA
SD31781OtherSANFORD HEALTH PLAN
SD41194500700OtherNEBRASKA MEDICAID
SD0539OtherDAKOTACARE
SD4995927OtherWELLMARK BCBS
SD119312100OtherWYOMING MEDICAID
SD0122934OtherMEDICA
SD0539OtherDAKOTACARE
SDP00118927Medicare PIN