Healthcare Provider Details

I. General information

NPI: 1386912947
Provider Name (Legal Business Name): BRIAN S WALTERS NP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/09/2011
Last Update Date: 07/09/2021
Certification Date: 07/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 PLAZA DR STE 400
ROSTRAVER TWP PA
15012-4019
US

IV. Provider business mailing address

800 PLAZA DR STE 400
ROSTRAVER TWP PA
15012-4019
US

V. Phone/Fax

Practice location:
  • Phone: 724-379-5802
  • Fax: 724-823-0286
Mailing address:
  • Phone: 724-379-5802
  • Fax: 724-823-0286

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberSP011695
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: