Provider Demographics
NPI:1285913517
Name:WALKER, MYRANDA DAWN (PA-C)
Entity type:Individual
Prefix:
First Name:MYRANDA
Middle Name:DAWN
Last Name:WALKER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MYRANDA
Other - Middle Name:DAWN
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1086 FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15905-4305
Mailing Address - Country:US
Mailing Address - Phone:814-536-7851
Mailing Address - Fax:814-534-5059
Practice Address - Street 1:1086 FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15905-4305
Practice Address - Country:US
Practice Address - Phone:814-536-7851
Practice Address - Fax:814-534-5059
Is Sole Proprietor?:No
Enumeration Date:2011-08-04
Last Update Date:2014-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA054986363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant