Provider Demographics
NPI:1952724403
Name:WALTERS, RUSSELL (PA-C)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:
Last Name:WALTERS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1431 CENTERPOINT BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37932-1984
Mailing Address - Country:US
Mailing Address - Phone:865-985-7012
Mailing Address - Fax:865-291-3224
Practice Address - Street 1:110 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37760-5281
Practice Address - Country:US
Practice Address - Phone:865-471-2300
Practice Address - Fax:865-471-2463
Is Sole Proprietor?:No
Enumeration Date:2014-02-03
Last Update Date:2021-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
TN2489363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant