Provider Demographics
NPI:1558508085
Name:WALKER, BEAU G (PA)
Entity Type:Individual
Prefix:
First Name:BEAU
Middle Name:G
Last Name:WALKER
Suffix:
Gender:M
Credentials:PA
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Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-345-6545
Mailing Address - Fax:208-345-1213
Practice Address - Street 1:333 N 1ST ST
Practice Address - Street 2:SUITE 280
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-6100
Practice Address - Country:US
Practice Address - Phone:208-345-6545
Practice Address - Fax:208-345-1213
Is Sole Proprietor?:No
Enumeration Date:2009-01-21
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IDPA-788363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID20000852Medicare PIN