Provider Demographics
NPI:1679891907
Name:WALTER, PATRICK ROGER (PA)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:ROGER
Last Name:WALTER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:8171 31ST ST SE UNIT 6
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:ND
Mailing Address - Zip Code:58401-9258
Mailing Address - Country:US
Mailing Address - Phone:701-252-7067
Mailing Address - Fax:
Practice Address - Street 1:904 5TH AVE NE
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:ND
Practice Address - Zip Code:58401-3437
Practice Address - Country:US
Practice Address - Phone:701-253-4020
Practice Address - Fax:701-253-4040
Is Sole Proprietor?:No
Enumeration Date:2010-05-11
Last Update Date:2012-10-25
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND71138Medicaid
ND71138Medicaid
NDN715266Medicare PIN