Provider Demographics
NPI:1134610363
Name:WALKER, BROCK KENYON (PT, DPT)
Entity type:Individual
Prefix:
First Name:BROCK
Middle Name:KENYON
Last Name:WALKER
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3467 N ELMSTONE AVE
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-4911
Mailing Address - Country:US
Mailing Address - Phone:435-773-2181
Mailing Address - Fax:
Practice Address - Street 1:600 N ROBBINS RD STE 101
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-4567
Practice Address - Country:US
Practice Address - Phone:208-385-3069
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-23
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID5768225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist