Healthcare Provider Details

I. General information

NPI: 1154370096
Provider Name (Legal Business Name): WALTER H JOYNER PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2006
Last Update Date: 09/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6300 N WICKHAM RD SUITE 101-108
MELBOURNE FL
32940-2028
US

IV. Provider business mailing address

6300 N WICKHAM RD SUITE 101-108
MELBOURNE FL
32940-2028
US

V. Phone/Fax

Practice location:
  • Phone: 321-253-2169
  • Fax: 321-253-1720
Mailing address:
  • Phone: 321-253-2169
  • Fax: 321-253-1720

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA3157
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: