Provider Demographics
NPI:1992162242
Name:WALLS, KEN CARLSON (PHD, MPAS, DO)
Entity type:Individual
Prefix:DR
First Name:KEN
Middle Name:CARLSON
Last Name:WALLS
Suffix:
Gender:M
Credentials:PHD, MPAS, DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12143 DEWAR DR
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92505-4106
Mailing Address - Country:US
Mailing Address - Phone:314-488-5943
Mailing Address - Fax:
Practice Address - Street 1:10800 MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92505-3043
Practice Address - Country:US
Practice Address - Phone:951-353-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-18
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
CAPTL1723207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1992162242Medicaid
CA1992162242Medicaid