Provider Demographics
NPI:1881770840
Name:WALKER, MARK C (PHD, PT)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:C
Last Name:WALKER
Suffix:
Gender:M
Credentials:PHD, PT
Other - Prefix:
Other - First Name:MARK
Other - Middle Name:C
Other - Last Name:WALKER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD, PT
Mailing Address - Street 1:771W 450 S A
Mailing Address - Street 2:
Mailing Address - City:SPRINGVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84663-2222
Mailing Address - Country:US
Mailing Address - Phone:801-704-9405
Mailing Address - Fax:801-704-9407
Practice Address - Street 1:655 E 400 S
Practice Address - Street 2:SUITE G
Practice Address - City:SPRINGVILLE
Practice Address - State:UT
Practice Address - Zip Code:84663
Practice Address - Country:US
Practice Address - Phone:801-787-0484
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2015-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT114536-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0057466Medicare PIN
R95528Medicare UPIN