Provider Demographics
NPI:1770890345
Name:WALTER, MARY K (PA)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:K
Last Name:WALTER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
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Mailing Address - Street 1:1561 THIRD ST STE G
Mailing Address - Street 2:
Mailing Address - City:NAPA
Mailing Address - State:CA
Mailing Address - Zip Code:94559-2861
Mailing Address - Country:US
Mailing Address - Phone:707-259-2000
Mailing Address - Fax:707-259-0181
Practice Address - Street 1:1222 PINE ST
Practice Address - Street 2:
Practice Address - City:SAINT HELENA
Practice Address - State:CA
Practice Address - Zip Code:94574-1830
Practice Address - Country:US
Practice Address - Phone:707-963-3641
Practice Address - Fax:707-963-8462
Is Sole Proprietor?:No
Enumeration Date:2010-09-02
Last Update Date:2010-09-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAPA11328363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ZZZ00607ZMedicare PIN