Provider Demographics
NPI:1003920968
Name:WALTERS, TAMMY ELAINE (PA-C)
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:ELAINE
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 1:100 STATE ST
Mailing Address - Street 2:
Mailing Address - City:EMPORIA
Mailing Address - State:VA
Mailing Address - Zip Code:23847-2040
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:125 BUENA VISTA CIR
Practice Address - Street 2:PAVILLION
Practice Address - City:SOUTH HILL
Practice Address - State:VA
Practice Address - Zip Code:23970-1431
Practice Address - Country:US
Practice Address - Phone:434-447-3151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110002186363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAS83373Medicare UPIN