Basic Information
| Provider Information | |||||||||
| NPI: | 1528050283 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LAJARA-NANSON | ||||||||
| FirstName: | WALTER | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1401 25TH STREET SOUTH | ||||||||
| Address2: | 3RD FLOOR | ||||||||
| City: | GREAT FALLS | ||||||||
| State: | MT | ||||||||
| PostalCode: | 594055183 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4067318888 | ||||||||
| FaxNumber: | 4067318876 | ||||||||
| Practice Location | |||||||||
| Address1: | 1401 25TH STREET SOUTH | ||||||||
| Address2: | 3RD FLOOR | ||||||||
| City: | GREAT FALLS | ||||||||
| State: | MT | ||||||||
| PostalCode: | 594055183 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4067318888 | ||||||||
| FaxNumber: | 4067318876 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2005 | ||||||||
| LastUpdateDate: | 04/05/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | L4510 | TX | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | 75041 | MT | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 100056860A | 05 | OK | MEDICAID |