Provider Demographics
NPI:1780302604
Name:WALKER, CONNOR ROSS
Entity type:Individual
Prefix:
First Name:CONNOR
Middle Name:ROSS
Last Name:WALKER
Suffix:
Gender:M
Credentials:
Other - Prefix:MS
Other - First Name:GWYN
Other - Middle Name:ROSE
Other - Last Name:WALKER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3110 N 24TH ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98406-6618
Mailing Address - Country:US
Mailing Address - Phone:217-254-5528
Mailing Address - Fax:
Practice Address - Street 1:8909 GRAVELLY LAKE DR SW STE D
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-3101
Practice Address - Country:US
Practice Address - Phone:360-323-2605
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-17
Last Update Date:2022-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA374U00000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No374U00000XNursing Service Related ProvidersHome Health Aide