Provider Demographics
NPI:1336209188
Name:WALTON, SHAWN ROBERT
Entity Type:Individual
Prefix:MR
First Name:SHAWN
Middle Name:ROBERT
Last Name:WALTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2410 PIERCE STREET
Mailing Address - Street 2:
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51104
Mailing Address - Country:US
Mailing Address - Phone:712-255-7607
Mailing Address - Fax:712-255-4507
Practice Address - Street 1:2410 PIERCE STREET
Practice Address - Street 2:
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51104
Practice Address - Country:US
Practice Address - Phone:712-255-7607
Practice Address - Fax:712-255-4507
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2014-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA07610122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025415600Medicaid
IA0102343Medicaid