Healthcare Provider Details

I. General information

NPI: 1245196377
Provider Name (Legal Business Name): MARCOS ANTONIO WALTERS RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/02/2026
Last Update Date: 01/02/2026
Certification Date: 01/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2450 S TELSHOR BLVD
LAS CRUCES NM
88011-5069
US

IV. Provider business mailing address

412 W ADAMS AVE APT C
KIRKWOOD MO
63122-4052
US

V. Phone/Fax

Practice location:
  • Phone: 505-308-3145
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number2021006362
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: