Individual
DEREK WALTON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
CRNA
Contact information
Practice address
2600 GREENBUSH ST, LAFAYETTE, IN 47904-2477
(765) 448-8000
(765) 838-5150
Mailing address
PO BOX 5545, LAFAYETTE, IN 47903-5545
(765) 448-8000
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
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