Provider Demographics
NPI:1518966019
Name:SHANK, WALTER A JR (MD)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:A
Last Name:SHANK
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 NICHOLASVILLE RD
Mailing Address - Street 2:STE 106
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-2518
Mailing Address - Country:US
Mailing Address - Phone:859-278-5926
Mailing Address - Fax:859-276-3189
Practice Address - Street 1:2101 NICHOLASVILLE RD
Practice Address - Street 2:STE 106
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-2518
Practice Address - Country:US
Practice Address - Phone:859-278-5926
Practice Address - Fax:859-276-3189
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY28899207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64288996Medicaid
218904Medicare ID - Type Unspecified
KY64288996Medicaid