Provider Demographics
NPI:1457668733
Name:WALTERS, SCOTT LOUIS (PA)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:LOUIS
Last Name:WALTERS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 E OLNEY AVE STE 400
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19120-2470
Mailing Address - Country:US
Mailing Address - Phone:215-456-7000
Mailing Address - Fax:215-456-5926
Practice Address - Street 1:559 W GERMANTOWN PIKE
Practice Address - Street 2:
Practice Address - City:EAST NORRITON
Practice Address - State:PA
Practice Address - Zip Code:19403-4250
Practice Address - Country:US
Practice Address - Phone:610-233-3130
Practice Address - Fax:610-238-0252
Is Sole Proprietor?:No
Enumeration Date:2010-09-08
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH363A00000X
PAMA059933363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0070588Medicaid
PA103739850Medicaid