Healthcare Provider Details

I. General information

NPI: 1912521444
Provider Name (Legal Business Name): CHARLES BRADLEY WALTERS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2020
Last Update Date: 03/29/2024
Certification Date: 03/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

181 HILLCREST RD
MOBILE AL
36608-5306
US

IV. Provider business mailing address

PO BOX 746450
ATLANTA GA
30374-6450
US

V. Phone/Fax

Practice location:
  • Phone: 251-341-3800
  • Fax: 251-660-6333
Mailing address:
  • Phone: 866-401-3057
  • Fax: 318-868-6430

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2360
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number2360
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: