MEDICARE: PAUL ALLEN WALCK PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	OA000122L	PA
2	363A00000X	Physician Assistant	MA000930L	PA

General Provider Information

NPI Number	:	1215921705
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PAUL ALLEN WALCK PA

Provider Business Mailing Address
First Line	:	WOMACK 2817 ROCK MERRITT AVE
Second Line	:
City	:	FORT LIBERTY
State	:	NC
Zip	:	28310-0001
Country	:	US
Telephone Number	:	910-907-8258
Fax Number	:

Provider Business Practice Location Address
First Line	:	WOMACK 2817 ROCK MERRITT AVE
Second Line	:
City	:	FORT LIBERTY
State	:	NC
Zip	:	28310-0001
Country	:	US
Telephone Number	:	910-907-8258
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/10/2005
Last Update Date	:	03/29/2024

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Directions to “ PAUL ALLEN WALCK PA” Practice Location

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