Provider Demographics
NPI:1245579200
Name:WALTERS, JACOB ANDREW (PA-C)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:ANDREW
Last Name:WALTERS
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 1:3050 E RIVER BLUFF BLVD
Mailing Address - Street 2:
Mailing Address - City:OZARK
Mailing Address - State:MO
Mailing Address - Zip Code:65721-8807
Mailing Address - Country:US
Mailing Address - Phone:417-885-3000
Mailing Address - Fax:717-737-7197
Practice Address - Street 1:3050 E RIVER BLUFF BLVD
Practice Address - Street 2:
Practice Address - City:OZARK
Practice Address - State:MO
Practice Address - Zip Code:65721-8807
Practice Address - Country:US
Practice Address - Phone:417-885-3000
Practice Address - Fax:717-737-7197
Is Sole Proprietor?:No
Enumeration Date:2013-02-11
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA055982363A00000X, 363AM0700X, 363AS0400X
MO2021024722363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical