Provider Demographics
NPI:1861462285
Name:WALKER, JOHN LEE (MOMT)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:LEE
Last Name:WALKER
Suffix:
Gender:M
Credentials:MOMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29650 BRADLEY RD
Mailing Address - Street 2:
Mailing Address - City:SUN CITY
Mailing Address - State:CA
Mailing Address - Zip Code:92586-6521
Mailing Address - Country:US
Mailing Address - Phone:951-672-0455
Mailing Address - Fax:951-672-0206
Practice Address - Street 1:29650 BRADLEY RD
Practice Address - Street 2:
Practice Address - City:SUN CITY
Practice Address - State:CA
Practice Address - Zip Code:92586-6521
Practice Address - Country:US
Practice Address - Phone:951-672-0455
Practice Address - Fax:951-672-0206
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2007-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14705225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT0147050Medicaid
CA0PT147050Medicare PIN