Healthcare Provider Details

I. General information

NPI: 1104888015
Provider Name (Legal Business Name): GERALD KEITH WALTERS MS, PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 N. WOLFE ST BLALOCK 544 JOHNS HOPKINS MEDICINE DIVISION OF INTERVENTIONAL RADIO
BALTIMORE MD
21287-4010
US

IV. Provider business mailing address

1501 PARK HILL CT
FALLSTON MD
21047
US

V. Phone/Fax

Practice location:
  • Phone: 410-614-6938
  • Fax: 410-955-0233
Mailing address:
  • Phone: 443-686-0905
  • Fax: 410-879-2048

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC-00072
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberC0000072
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: