Provider Demographics
NPI:1871881375
Name:WALTON, GREGORY DEAN (CRNA)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:DEAN
Last Name:WALTON
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 POLE LINE ROAD WEST
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-5799
Mailing Address - Country:US
Mailing Address - Phone:208-814-1000
Mailing Address - Fax:208-814-0948
Practice Address - Street 1:801 POLE LINE ROAD WEST
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-5799
Practice Address - Country:US
Practice Address - Phone:208-814-1000
Practice Address - Fax:208-814-0948
Is Sole Proprietor?:No
Enumeration Date:2011-07-18
Last Update Date:2011-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDRNA799A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered