Healthcare Provider Details

I. General information

NPI: 1184042541
Provider Name (Legal Business Name): CHARLES WALKER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2014
Last Update Date: 09/13/2021
Certification Date: 09/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N ACADEMY AVE
DANVILLE PA
17822-9800
US

IV. Provider business mailing address

100 N ACADEMY AVE
DANVILLE PA
17822-4903
US

V. Phone/Fax

Practice location:
  • Phone: 570-271-6211
  • Fax:
Mailing address:
  • Phone: 570-271-6144
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License NumberMD471917
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: