1104888015 NPI number — MR. GERALD KEITH WALTERS MS, PA-C

Table of content: MR. GERALD KEITH WALTERS MS, PA-C (NPI 1104888015)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104888015 NPI number — MR. GERALD KEITH WALTERS MS, PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALTERS
Provider First Name:
GERALD
Provider Middle Name:
KEITH
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MS, PA-C
Provider Gender Code:
M

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:
1104888015
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1501 PARK HILL CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FALLSTON
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21047
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
443-686-0905
Provider Business Mailing Address Fax Number:
410-879-2048

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
600 N. WOLFE ST BLALOCK 544
Provider Second Line Business Practice Location Address:
JOHNS HOPKINS MEDICINE DIVISION OF INTERVENTIONAL RADIO
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21287-4010
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-614-6938
Provider Business Practice Location Address Fax Number:
410-955-0233
Provider Enumeration Date:
04/05/2006

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: 363AS0400X , with the licence number:  C0000072 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: C-00072 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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