Provider Demographics
NPI:1871563007
Name:WALKER, BRADLEY L
Entity type:Individual
Prefix:MR
First Name:BRADLEY
Middle Name:L
Last Name:WALKER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5033 REDFISH ST
Mailing Address - Street 2:
Mailing Address - City:CHUBBUCK
Mailing Address - State:ID
Mailing Address - Zip Code:83202-3031
Mailing Address - Country:US
Mailing Address - Phone:208-237-8376
Mailing Address - Fax:
Practice Address - Street 1:120 S RAILROAD AVE
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83204-3205
Practice Address - Country:US
Practice Address - Phone:208-236-5215
Practice Address - Fax:208-236-5201
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP-85A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily