Provider Demographics
NPI:1912655549
Name:WALTERS, ABIGALE LOUISE (PA)
Entity Type:Individual
Prefix:
First Name:ABIGALE
Middle Name:LOUISE
Last Name:WALTERS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15020 NC 242 HWY S
Mailing Address - Street 2:
Mailing Address - City:BLADENBORO
Mailing Address - State:NC
Mailing Address - Zip Code:28320-9216
Mailing Address - Country:US
Mailing Address - Phone:910-874-4023
Mailing Address - Fax:
Practice Address - Street 1:630 S MADISON ST
Practice Address - Street 2:
Practice Address - City:WHITEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28472-4130
Practice Address - Country:US
Practice Address - Phone:910-914-6625
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-14
Last Update Date:2022-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC001012037363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty