MEDICARE: DESTINY DEONNA WALTERS 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	363A00000X	Physician Assistant	1171842	NC

General Provider Information

NPI Number	:	1619503547
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DESTINY DEONNA WALTERS PA

Provider Business Mailing Address
First Line	:	PO BOX 60447
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28260-0447
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	9930 KINCEY AVE STE 300
Second Line	:
City	:	HUNTERSVILLE
State	:	NC
Zip	:	28078-6541
Country	:	US
Telephone Number	:	704-316-5600
Fax Number	:

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

Provider Enumeration Date	:	03/23/2020
Last Update Date	:	12/29/2025

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