Provider Demographics
NPI:1881216380
Name:WALKER, BRIAN RISLEY (LAC, MSTOM)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:RISLEY
Last Name:WALKER
Suffix:
Gender:M
Credentials:LAC, MSTOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:652 BORDEN RD
Mailing Address - Street 2:
Mailing Address - City:EARLVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13332-3226
Mailing Address - Country:US
Mailing Address - Phone:607-244-0288
Mailing Address - Fax:
Practice Address - Street 1:20 N. MAIN ST.
Practice Address - Street 2:
Practice Address - City:EARLVILLE
Practice Address - State:NY
Practice Address - Zip Code:13332-1333
Practice Address - Country:US
Practice Address - Phone:607-244-0288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-07
Last Update Date:2020-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006643-01171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist