Basic Information
| Provider Information | |||||||||
| NPI: | 1245579200 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALTERS | ||||||||
| FirstName: | JACOB | ||||||||
| MiddleName: | ANDREW | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3050 E RIVER BLUFF BLVD | ||||||||
| Address2: | |||||||||
| City: | OZARK | ||||||||
| State: | MO | ||||||||
| PostalCode: | 657218807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178853000 | ||||||||
| FaxNumber: | 7177377197 | ||||||||
| Practice Location | |||||||||
| Address1: | 3050 E RIVER BLUFF BLVD | ||||||||
| Address2: | |||||||||
| City: | OZARK | ||||||||
| State: | MO | ||||||||
| PostalCode: | 657218807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178853000 | ||||||||
| FaxNumber: | 7177377197 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/11/2013 | ||||||||
| LastUpdateDate: | 08/18/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | MA055982 | PA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | MA055982 | PA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AS0400X | MA055982 | PA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363A00000X | 2021024722 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.