Provider Demographics
NPI:1316987498
Name:WALKO, SHANON (DO)
Entity type:Individual
Prefix:
First Name:SHANON
Middle Name:
Last Name:WALKO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175S WAVERLY RD
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-7906
Mailing Address - Country:US
Mailing Address - Phone:616-355-3896
Mailing Address - Fax:
Practice Address - Street 1:3235 N WELLNESS DR
Practice Address - Street 2:#120B
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49424-7264
Practice Address - Country:US
Practice Address - Phone:616-399-9522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI510103291207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H00153Medicare UPIN