Provider Demographics
NPI:1316372063
Name:WALKER, MITCHELL RYAN (DPT)
Entity type:Individual
Prefix:
First Name:MITCHELL
Middle Name:RYAN
Last Name:WALKER
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 VENTURE DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:SOUTH DAYTONA
Mailing Address - State:FL
Mailing Address - Zip Code:32119-3478
Mailing Address - Country:US
Mailing Address - Phone:386-763-0084
Mailing Address - Fax:
Practice Address - Street 1:401 VENTURE DR
Practice Address - Street 2:SUITE C
Practice Address - City:SOUTH DAYTONA
Practice Address - State:FL
Practice Address - Zip Code:32119-3478
Practice Address - Country:US
Practice Address - Phone:386-763-0084
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-12
Last Update Date:2013-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT28640225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1952392854Medicare NSC