Basic Information
| Provider Information | |||||||||
| NPI: | 1568758878 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALKER | ||||||||
| FirstName: | SEAN | ||||||||
| MiddleName: | THOMAS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 10700 E GEDDES AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | ENGLEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801123861 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037619190 | ||||||||
| FaxNumber: | 7208744462 | ||||||||
| Practice Location | |||||||||
| Address1: | 4021 AVENUE B | ||||||||
| Address2: | |||||||||
| City: | SCOTTSBLUFF | ||||||||
| State: | NE | ||||||||
| PostalCode: | 693614602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037619190 | ||||||||
| FaxNumber: | 7208744462 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2011 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 6577 | NE | N | Allopathic & Osteopathic Physicians | Internal Medicine | 2085R0202X | 57947 | CO | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 04-39693 | KS | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 390200000X | NM | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2085R0202X | 27792 | NE | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 561591YQ33 | 01 | CO | MEDICARE PIN | OTHER | 111257098 | 01 | KS | MEDICARE PIN | OTHER | 561591ZLJ3 | 01 | CO | MEDICARE PIN | OTHER | NA1214114 | 01 | NE | MEDICARE PIN | OTHER | 1568758878 | 05 | CO | MEDICAID | 561591YQN9 | 01 | CO | MEDICARE PIN | OTHER | KA3249089 | 01 | KS | MEDICARE PIN | OTHER | 561591YQ3L | 01 | CO | MEDICARE PIN | OTHER | 561591YQPG | 01 | CO | MEDICARE PIN | OTHER | NA1215112 | 01 | NE | MEDICARE PIN | OTHER | NA2517093 | 01 | NE | MEDICARE PIN | OTHER |