Provider Demographics
NPI:1881132942
Name:WALTON, SAMUEL RICHARD (ATC)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:RICHARD
Last Name:WALTON
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1214 SWAN LAKE DR APT 302
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22902-7266
Mailing Address - Country:US
Mailing Address - Phone:201-991-0659
Mailing Address - Fax:
Practice Address - Street 1:1214 SWAN LAKE DR APT 302
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22902-7266
Practice Address - Country:US
Practice Address - Phone:201-991-0659
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-08
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01260018722255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA70802201OtherATHLETIC TRAINING BOARD OF CERTIFICATION
VA0126001872OtherVIRGINIA BOARD OF MEDICINE LICENSE