Provider Demographics
NPI:1659836823
Name:WALTERS, ALVIN REED (FNP)
Entity Type:Individual
Prefix:DR
First Name:ALVIN
Middle Name:REED
Last Name:WALTERS
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12358 ELIZABETH WAY
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95949-6517
Mailing Address - Country:US
Mailing Address - Phone:425-478-7051
Mailing Address - Fax:
Practice Address - Street 1:155 GLASSON WAY
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-5723
Practice Address - Country:US
Practice Address - Phone:530-274-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-01
Last Update Date:2019-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95010726363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
F01191203OtherAANP BOARD CERTIFICATION NUMBER
CA95010726OtherLICENSE/ FURNISHING NUMBER