Provider Demographics
NPI:1225118607
Name:WALKER, NICOLE RAE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:RAE
Last Name:WALKER
Suffix:
Gender:F
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 1:2060 W WHISPERING WIND DR
Mailing Address - Street 2:STE 173
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85085-2869
Mailing Address - Country:US
Mailing Address - Phone:623-565-5060
Mailing Address - Fax:623-565-5061
Practice Address - Street 1:4344 W BELL RD
Practice Address - Street 2:SUITE 102
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-3589
Practice Address - Country:US
Practice Address - Phone:602-588-4040
Practice Address - Fax:602-942-2391
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2015-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3544363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ111734Medicare PIN