Healthcare Provider Details

I. General information

NPI: 1457473241
Provider Name (Legal Business Name): JOHN LEROY WALKER CSA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2007
Last Update Date: 08/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3688 CREEKSTONE DR
PEACHTREE CORNERS GA
30092-2474
US

IV. Provider business mailing address

PO BOX 923821
NORCROSS GA
30010-3821
US

V. Phone/Fax

Practice location:
  • Phone: 678-691-6529
  • Fax: 770-840-7464
Mailing address:
  • Phone: 770-985-4257
  • Fax: 770-985-4258

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: