Healthcare Provider Details

I. General information

NPI: 1285375188
Provider Name (Legal Business Name): D'ANDRA MIXON-WALKER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2022
Last Update Date: 04/05/2022
Certification Date: 04/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7450 W 63RD ST
SUMMIT IL
60501-1816
US

IV. Provider business mailing address

1724 E 36TH AVE
DENVER CO
80205-4033
US

V. Phone/Fax

Practice location:
  • Phone: 708-458-0757
  • Fax:
Mailing address:
  • Phone: 720-327-0122
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: