Provider Demographics
NPI:1649414905
Name:KIRBY, WALTER R (PA-C)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:R
Last Name:KIRBY
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 1:86 WREN ST
Mailing Address - Street 2:
Mailing Address - City:BARNWELL
Mailing Address - State:SC
Mailing Address - Zip Code:29812-1529
Mailing Address - Country:US
Mailing Address - Phone:803-259-5762
Mailing Address - Fax:
Practice Address - Street 1:333 REVOLUTIONARY TRL
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:SC
Practice Address - Zip Code:29827-7109
Practice Address - Country:US
Practice Address - Phone:803-632-2533
Practice Address - Fax:803-632-2451
Is Sole Proprietor?:No
Enumeration Date:2009-04-29
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2214363A00000X
1710I1003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC2119PAMedicaid
SC2214OtherMEDICAL LICENSE