Provider Demographics
NPI:1033651989
Name:WALKER, JACOB (PA-C)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
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 1:738 MONROE ST
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-3857
Mailing Address - Country:US
Mailing Address - Phone:208-404-2333
Mailing Address - Fax:
Practice Address - Street 1:382 N OVERLAND AVE
Practice Address - Street 2:
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318-3433
Practice Address - Country:US
Practice Address - Phone:208-678-6996
Practice Address - Fax:208-678-6866
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-09
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-1452363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical