1386085090 NPI number — TEKESA M WALKER FNP

Table of content: TEKESA M WALKER FNP (NPI 1386085090)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386085090 NPI number — TEKESA M WALKER FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALKER
Provider First Name:
TEKESA
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1386085090
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/19/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1425 HIGHWAY 34 E
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEWNAN
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30265-1323
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-304-3724
Provider Business Mailing Address Fax Number:
770-304-3726

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2101 NEWNAN CROSSING BLVD E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEWNAN
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30265-2406
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-552-6200
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/10/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  RN214831 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 003137434 , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 202I508141 . This is a "MEDICARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".