Provider Demographics
NPI:1609871987
Name:WALTHER, LARRY L (PA)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:L
Last Name:WALTHER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5300 N INDEPENDENCE AVE
Mailing Address - Street 2:280
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-5556
Mailing Address - Country:US
Mailing Address - Phone:918-540-7758
Mailing Address - Fax:918-540-7763
Practice Address - Street 1:21 W CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:OK
Practice Address - Zip Code:74354-6815
Practice Address - Country:US
Practice Address - Phone:918-542-3900
Practice Address - Fax:918-542-3928
Is Sole Proprietor?:No
Enumeration Date:2005-06-14
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK681363A00000X
MO2001025778363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100186200AMedicaid
OK200468380FMedicaid
OK078603YKW9Medicare PIN
OK100186200AMedicaid