Provider Demographics
NPI:1235493222
Name:WALTER, NICHOLAS (MD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:
Last Name:WALTER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2927 N 7TH AVE
Mailing Address - Street 2:PEPPERTREE BUILDING - WINDOW #3
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-4102
Mailing Address - Country:US
Mailing Address - Phone:602-406-3153
Mailing Address - Fax:602-406-7176
Practice Address - Street 1:2927 N 7TH AVE
Practice Address - Street 2:PEPPERTREE BUILDING - WINDOW #3
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-4102
Practice Address - Country:US
Practice Address - Phone:602-406-3153
Practice Address - Fax:602-406-7176
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-25
Last Update Date:2012-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZR73521207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAR73521OtherTRAINING PERMIT