Provider Demographics
NPI:1790019800
Name:WALTON, CHARLES EDWARD II (PA)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:EDWARD
Last Name:WALTON
Suffix:II
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:PO BOX 936857
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31193-6857
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2131 S 17TH ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-7407
Practice Address - Country:US
Practice Address - Phone:910-667-7000
Practice Address - Fax:910-815-5698
Is Sole Proprietor?:No
Enumeration Date:2009-09-22
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-02027363A00000X
NC001002027363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8101624Medicaid
NC1790019800Medicaid
MW2056679OtherDEA
NCNC8922FMedicare PIN
NC2762071AMedicare PIN
NCNC8922IMedicare PIN
NC1790019800Medicaid
NCNC8922EMedicare PIN