Healthcare Provider Details

I. General information

NPI: 1245579200
Provider Name (Legal Business Name): JACOB ANDREW WALTERS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/11/2013
Last Update Date: 08/18/2021
Certification Date: 08/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3050 E RIVER BLUFF BLVD
OZARK MO
65721-8807
US

IV. Provider business mailing address

3050 E RIVER BLUFF BLVD
OZARK MO
65721-8807
US

V. Phone/Fax

Practice location:
  • Phone: 417-885-3000
  • Fax: 717-737-7197
Mailing address:
  • Phone: 417-885-3000
  • Fax: 717-737-7197

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA055982
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberMA055982
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberMA055982
License Number StatePA
# 4
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2021024722
License Number StateMO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: