Provider Demographics
NPI:1609813229
Name:BISHOP, WALTER LEE (PT)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:LEE
Last Name:BISHOP
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2003 ALICE ST
Mailing Address - Street 2:
Mailing Address - City:WAYCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:31501-6209
Mailing Address - Country:US
Mailing Address - Phone:912-285-0053
Mailing Address - Fax:912-283-9289
Practice Address - Street 1:2003 ALICE ST
Practice Address - Street 2:
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501-6209
Practice Address - Country:US
Practice Address - Phone:912-285-0053
Practice Address - Fax:912-283-9289
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2017-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT007644225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00829509OtherRAILROAD MEDICARE
GA390574913NMedicaid
202I650313Medicare PIN