Healthcare Provider Details

I. General information

NPI: 1063190551
Provider Name (Legal Business Name): HEATHER WALTON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2023
Last Update Date: 08/31/2023
Certification Date: 08/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4850 MILLENIA BLVD
ORLANDO FL
32839-6012
US

IV. Provider business mailing address

4850 MILLENIA BLVD
ORLANDO FL
32839-6012
US

V. Phone/Fax

Practice location:
  • Phone: 407-264-5601
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number9117455
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA9117455
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: