Provider Demographics
NPI:1962563585
Name:WALKER, GARY BLAINE (PA-C)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:BLAINE
Last Name:WALKER
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 1:280 TEAGUE DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-3376
Mailing Address - Country:US
Mailing Address - Phone:909-394-6160
Mailing Address - Fax:
Practice Address - Street 1:421 E MERCED AVE
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-5023
Practice Address - Country:US
Practice Address - Phone:626-918-1881
Practice Address - Fax:626-918-3618
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2010-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA14463363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABN603ZMedicare PIN
CAS64132Medicare UPIN
CAWPA14463AMedicare ID - Type Unspecified