Provider Demographics
NPI:1164534491
Name:WALKER, KRISTY KELLER (PA-C)
Entity Type:Individual
Prefix:
First Name:KRISTY
Middle Name:KELLER
Last Name:WALKER
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 1:4375 N. VANTAGE DR.
Mailing Address - Street 2:SUITE 305
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703
Mailing Address - Country:US
Mailing Address - Phone:479-443-5100
Mailing Address - Fax:479-443-5117
Practice Address - Street 1:4375 N. VANTAGE DR.
Practice Address - Street 2:SUITE 305
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703
Practice Address - Country:US
Practice Address - Phone:479-443-5100
Practice Address - Fax:479-443-5117
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2013-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPA-232363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARP71655Medicare UPIN