Provider Demographics
NPI:1265207849
Name:QUIJADA HENRIQUEZ, WALTER CORNELIO (SA-C)
Entity type:Individual
Prefix:
First Name:WALTER
Middle Name:CORNELIO
Last Name:QUIJADA HENRIQUEZ
Suffix:
Gender:M
Credentials:SA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:507 DERBY PL
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:TN
Mailing Address - Zip Code:37167-5915
Mailing Address - Country:US
Mailing Address - Phone:629-200-5895
Mailing Address - Fax:
Practice Address - Street 1:507 DERBY PL
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:TN
Practice Address - Zip Code:37167-5915
Practice Address - Country:US
Practice Address - Phone:629-200-5895
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-24
Last Update Date:2023-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN23-704246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant