Individual
DEREK WALTON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
CRNA
Taxonomy
Speciality
Code
Description
License number
State
163W00000X
Registered Nurse
Primary
28184479A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000001069136
ANTHEM PROVIDER NUMBER
IN
05
—
201411960
—
IN
Enumeration date
07/27/2016
Last updated
03/10/2017
Update your record
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