Provider Demographics
NPI:1760145312
Name:WALIN, ANTHONY WAYNE (PTA)
Entity Type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:WAYNE
Last Name:WALIN
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2895 N MYRTLE RD
Mailing Address - Street 2:
Mailing Address - City:MYRTLE CREEK
Mailing Address - State:OR
Mailing Address - Zip Code:97457-9660
Mailing Address - Country:US
Mailing Address - Phone:619-300-5361
Mailing Address - Fax:
Practice Address - Street 1:2901 E BARNETT RD
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-8308
Practice Address - Country:US
Practice Address - Phone:541-779-4221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-20
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR9881225500000X, 225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty
No225500000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistGroup - Single Specialty