Provider Demographics
NPI:1447343058
Name:WALKOWSKI, PAM (PTA)
Entity type:Individual
Prefix:MS
First Name:PAM
Middle Name:
Last Name:WALKOWSKI
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23821 GRANT RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46619-2240
Mailing Address - Country:US
Mailing Address - Phone:574-251-9368
Mailing Address - Fax:
Practice Address - Street 1:1005 N HICKORY RD
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46615-3723
Practice Address - Country:US
Practice Address - Phone:574-233-5754
Practice Address - Fax:574-233-7406
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06001760A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant