Provider Demographics
NPI:1295707677
Name:WALKER, COREY WYN (MD)
Entity type:Individual
Prefix:
First Name:COREY
Middle Name:WYN
Last Name:WALKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1350 N 500 E
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-2400
Mailing Address - Country:US
Mailing Address - Phone:435-792-1518
Mailing Address - Fax:435-792-1647
Practice Address - Street 1:1350 N 500 E
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-2400
Practice Address - Country:US
Practice Address - Phone:435-792-1518
Practice Address - Fax:435-792-1647
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2012-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6135223-1205207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT942854058659Medicaid
UT942854058659Medicaid
UTI62359Medicare UPIN