Healthcare Provider Details

I. General information

NPI: 1407890049
Provider Name (Legal Business Name): WALTER SAMUEL HURTADO PA C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 02/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1377 E HERNDON AVE SUITE 104
FRESNO CA
93720-3022
US

IV. Provider business mailing address

1377 E HERNDON AVE SUITE 104
FRESNO CA
93720-3022
US

V. Phone/Fax

Practice location:
  • Phone: 559-450-7455
  • Fax: 559-450-7473
Mailing address:
  • Phone: 559-450-7455
  • Fax: 559-450-7473

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA16233
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: