Provider Demographics
NPI:1679226203
Name:WALKER, ANTIQUA
Entity Type:Individual
Prefix:
First Name:ANTIQUA
Middle Name:
Last Name:WALKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2751 BUFORD HWY NE STE 700
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30324-5510
Mailing Address - Country:US
Mailing Address - Phone:404-520-2492
Mailing Address - Fax:
Practice Address - Street 1:2751 BUFORD HWY NE STE 700
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30324-5510
Practice Address - Country:US
Practice Address - Phone:877-839-3988
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-02
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA302R00000X
GA11D2240079247ZC0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247ZC0005XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyClinical Laboratory Director, Non-physician
No302R00000XManaged Care OrganizationsHealth Maintenance Organization