Healthcare Provider Details

I. General information

NPI: 1215579982
Provider Name (Legal Business Name): ANFERNEE JEROME WALKER CSA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/14/2019
Last Update Date: 02/27/2020
Certification Date: 02/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

990 THOUSAND OAKS DR
LAWRENCEVILLE GA
30043-3123
US

IV. Provider business mailing address

990 THOUSAND OAKS DR
LAWRENCEVILLE GA
30043-3123
US

V. Phone/Fax

Practice location:
  • Phone: 470-262-2848
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number5026
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: