Provider Demographics
NPI:1457352734
Name:STEIN, WALTER A (PA)
Entity Type:Individual
Prefix:MR
First Name:WALTER
Middle Name:A
Last Name:STEIN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:444 HOSPITAL WAY
Mailing Address - Street 2:SUITE 801
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-2745
Mailing Address - Country:US
Mailing Address - Phone:208-232-6214
Mailing Address - Fax:208-233-3416
Practice Address - Street 1:444 HOSPITAL WAY
Practice Address - Street 2:SUITE 801
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-2745
Practice Address - Country:US
Practice Address - Phone:208-232-6214
Practice Address - Fax:208-233-3416
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2010-10-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IDPA171363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDQ15919Medicare UPIN
ID1665676Medicare ID - Type Unspecified