Provider Demographics
NPI:1386077196
Name:WALTERS, BRADLEY (PAC)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:
Last Name:WALTERS
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 BROADWAY BLVD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-2372
Mailing Address - Country:US
Mailing Address - Phone:505-225-2500
Mailing Address - Fax:505-225-2025
Practice Address - Street 1:610 BROADWAY BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-2372
Practice Address - Country:US
Practice Address - Phone:505-225-2500
Practice Address - Fax:505-225-2025
Is Sole Proprietor?:No
Enumeration Date:2013-08-15
Last Update Date:2025-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2013-0052363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM58688005Medicaid
NM390449YR41Medicare PIN