Provider Demographics
NPI:1063182384
Name:WALKER, DEONTAY
Entity type:Individual
Prefix:
First Name:DEONTAY
Middle Name:
Last Name:WALKER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 945375
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30394-5375
Mailing Address - Country:US
Mailing Address - Phone:516-945-3000
Mailing Address - Fax:704-248-5537
Practice Address - Street 1:247 S MAIN ST
Practice Address - Street 2:
Practice Address - City:REIDSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30453-4605
Practice Address - Country:US
Practice Address - Phone:516-945-3000
Practice Address - Fax:704-248-5537
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-17
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH67.000424367H00000X
GA12599367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist AssistantGroup - Single Specialty