Provider Demographics
NPI:1326004094
Name:SPEIRS, WALTER GLEN (PA-C)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:GLEN
Last Name:SPEIRS
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 1:844 OLD TUNNEL RD
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-8524
Mailing Address - Country:US
Mailing Address - Phone:530-274-9762
Mailing Address - Fax:530-273-7255
Practice Address - Street 1:844 OLD TUNNEL RD
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-8524
Practice Address - Country:US
Practice Address - Phone:530-274-9762
Practice Address - Fax:530-273-7255
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22863363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO50006878Medicaid
CO50006878Medicaid
COC811414Medicare PIN