Provider Demographics
NPI:1639711187
Name:WALKER, IAN ANTHONY (ATC, LAT)
Entity Type:Individual
Prefix:MR
First Name:IAN
Middle Name:ANTHONY
Last Name:WALKER
Suffix:
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4004 SUN LAKE DR
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63301-3059
Mailing Address - Country:US
Mailing Address - Phone:703-209-3967
Mailing Address - Fax:
Practice Address - Street 1:209 S KINGSHIGHWAY ST
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63301-1693
Practice Address - Country:US
Practice Address - Phone:636-949-4346
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-16
Last Update Date:2019-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20190320642255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer