Provider Demographics
NPI:1194948471
Name:WALNUM, PAUL KEITH (LAT, ATC, CSCS)
Entity type:Individual
Prefix:MR
First Name:PAUL
Middle Name:KEITH
Last Name:WALNUM
Suffix:
Gender:M
Credentials:LAT, ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3470 SHERBURNE LN
Mailing Address - Street 2:APT. D
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46222-1639
Mailing Address - Country:US
Mailing Address - Phone:317-925-0803
Mailing Address - Fax:
Practice Address - Street 1:324 E NEW YORK ST
Practice Address - Street 2:SUITE 300
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46204-2141
Practice Address - Country:US
Practice Address - Phone:317-972-1180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36000458A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer