Provider Demographics
NPI:1154516789
Name:THOMAS, WALTER (PAC)
Entity type:Individual
Prefix:
First Name:WALTER
Middle Name:
Last Name:THOMAS
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12044 BRADDOCK DR
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90230-5811
Mailing Address - Country:US
Mailing Address - Phone:310-398-6408
Mailing Address - Fax:
Practice Address - Street 1:12044 BRADDOCK DR
Practice Address - Street 2:
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90230-5811
Practice Address - Country:US
Practice Address - Phone:310-398-6408
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-06
Last Update Date:2007-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA15198363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical