Provider Demographics
NPI:1093538647
Name:IZARRA, WALTER JOHN
Entity type:Individual
Prefix:
First Name:WALTER
Middle Name:JOHN
Last Name:IZARRA
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 1:4524 SHAKY LEAF LN N FL 32224
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224-7611
Mailing Address - Country:US
Mailing Address - Phone:904-534-2624
Mailing Address - Fax:
Practice Address - Street 1:4524 SHAKY LEAF LN N FL 32224
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32224-7611
Practice Address - Country:US
Practice Address - Phone:904-534-2624
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-04
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA32071225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist