Provider Demographics
NPI:1104888015
Name:WALTERS, GERALD KEITH (MS, PA-C)
Entity type:Individual
Prefix:MR
First Name:GERALD
Middle Name:KEITH
Last Name:WALTERS
Suffix:
Gender:M
Credentials:MS, PA-C
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Mailing Address - Street 1:1501 PARK HILL CT
Mailing Address - Street 2:
Mailing Address - City:FALLSTON
Mailing Address - State:MD
Mailing Address - Zip Code:21047
Mailing Address - Country:US
Mailing Address - Phone:443-686-0905
Mailing Address - Fax:410-879-2048
Practice Address - Street 1:600 N. WOLFE ST BLALOCK 544
Practice Address - Street 2:JOHNS HOPKINS MEDICINE DIVISION OF INTERVENTIONAL RADIO
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21287-4010
Practice Address - Country:US
Practice Address - Phone:410-614-6938
Practice Address - Fax:410-955-0233
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2023-03-07
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MDC0000072363AS0400X
MDC-00072363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDMW0475803OtherDEA
MD178L60ZZMedicare ID - Type Unspecified
MD192778YSJMedicare PIN
MDMW0475803OtherDEA