Provider Demographics
NPI:1164970570
Name:WALKER, JEREMY (FNP-C)
Entity Type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:
Last Name:WALKER
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:634 ELK EST
Mailing Address - Street 2:
Mailing Address - City:ELKVIEW
Mailing Address - State:WV
Mailing Address - Zip Code:25071-9551
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:122 CENTER ST
Practice Address - Street 2:
Practice Address - City:CLAY
Practice Address - State:WV
Practice Address - Zip Code:25043-7046
Practice Address - Country:US
Practice Address - Phone:304-587-7301
Practice Address - Fax:304-587-2464
Is Sole Proprietor?:No
Enumeration Date:2016-09-14
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV82794363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1164970570 (THSPP)Medicaid
WV3810024049 (GROUP)Medicaid
WV1164970570 (THSPP)Medicaid
WV3810024049 (GROUP)Medicaid