Provider Demographics
NPI:1043026685
Name:WALTER, JORDYN RILEY (PA-C)
Entity type:Individual
Prefix:
First Name:JORDYN
Middle Name:RILEY
Last Name:WALTER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 20557
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59104-0557
Mailing Address - Country:US
Mailing Address - Phone:406-696-3412
Mailing Address - Fax:
Practice Address - Street 1:508 STOCKTRAIL AVE
Practice Address - Street 2:
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82716-3582
Practice Address - Country:US
Practice Address - Phone:307-686-1413
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-09
Last Update Date:2024-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPT1322363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant