Provider Demographics
NPI:1124246525
Name:WALKER, IVAN LEONARD (PA-C)
Entity type:Individual
Prefix:
First Name:IVAN
Middle Name:LEONARD
Last Name:WALKER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 FRANKLIN ST NE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20002-1008
Mailing Address - Country:US
Mailing Address - Phone:202-588-9320
Mailing Address - Fax:202-517-9184
Practice Address - Street 1:3020 14TH ST NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20009-6865
Practice Address - Country:US
Practice Address - Phone:202-745-4300
Practice Address - Fax:202-232-0723
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPA030359363A00000X
MDC03341363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant