Provider Demographics
NPI:1699083675
Name:WALTERS, MARIAM SEDA (PA-C)
Entity type:Individual
Prefix:MS
First Name:MARIAM
Middle Name:SEDA
Last Name:WALTERS
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 1:10855 TERRA VISTA PKWY
Mailing Address - Street 2:APT 111
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-6381
Mailing Address - Country:US
Mailing Address - Phone:310-729-6373
Mailing Address - Fax:
Practice Address - Street 1:1798 N GAREY AVE
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-2918
Practice Address - Country:US
Practice Address - Phone:909-865-9828
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-23
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA21183363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA21183OtherCALIFORNIA LICENSE NUMBER