Provider Demographics
NPI:1730309758
Name:SELVAGE, WALTER DAVID (PA-C)
Entity Type:Individual
Prefix:MR
First Name:WALTER
Middle Name:DAVID
Last Name:SELVAGE
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 1:2720 CALLE CEDRO
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-5297
Mailing Address - Country:US
Mailing Address - Phone:505-660-4282
Mailing Address - Fax:
Practice Address - Street 1:1190 S SAINT FRANCIS DR
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4173
Practice Address - Country:US
Practice Address - Phone:505-827-0006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM94-PA05363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant