Healthcare Provider Details

I. General information

NPI: 1114360815
Provider Name (Legal Business Name): JEREMY WALKER PATRICK PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2013
Last Update Date: 03/22/2022
Certification Date: 03/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

DOD USAF NATO BASE
AVIANO PN
09603
IT

IV. Provider business mailing address

AVIANO MDG UNIT 6180
APO AE
09604
US

V. Phone/Fax

Practice location:
  • Phone: 632-632-9022
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1762
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA60567501
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9709
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: