Provider Demographics
NPI:1215924659
Name:WALTERS, JOHN T (PA-C)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:T
Last Name:WALTERS
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 1:1001 NOBLE ST
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-4922
Mailing Address - Country:US
Mailing Address - Phone:907-459-3500
Mailing Address - Fax:907-458-2628
Practice Address - Street 1:1001 NOBLE ST
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-4922
Practice Address - Country:US
Practice Address - Phone:907-458-2682
Practice Address - Fax:907-458-2628
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK142182363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMDA0001Medicaid
AKMDA0001Medicaid
AKMDA0001Medicaid
AKK161233Medicare PIN
MW1167192OtherDEA