Provider Demographics
NPI:1255881785
Name:WALTER, KAITLIN ROSE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:KAITLIN
Middle Name:ROSE
Last Name:WALTER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:KAITLIN
Other - Middle Name:ROSE
Other - Last Name:PULLANO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:219 RALSTON RD
Mailing Address - Street 2:
Mailing Address - City:SARVER
Mailing Address - State:PA
Mailing Address - Zip Code:16055-9335
Mailing Address - Country:US
Mailing Address - Phone:724-504-0549
Mailing Address - Fax:
Practice Address - Street 1:3001 GREEN BAY RD
Practice Address - Street 2:
Practice Address - City:NORTH CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60064-3048
Practice Address - Country:US
Practice Address - Phone:847-688-1900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-07
Last Update Date:2021-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.006003363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant