MEDICARE: CHARLES BRADLEY WALTERS PA-C

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	2360	AL
2	363AM0700X	Medical Physician Assistant	2360	AL

General Provider Information

NPI Number	:	1912521444
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLES BRADLEY WALTERS PA-C

Provider Business Mailing Address
First Line	:	PO BOX 746450
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30374-6450
Country	:	US
Telephone Number	:	866-401-3057
Fax Number	:	318-868-6430

Provider Business Practice Location Address
First Line	:	181 HILLCREST RD
Second Line	:
City	:	MOBILE
State	:	AL
Zip	:	36608-5306
Country	:	US
Telephone Number	:	251-341-3800
Fax Number	:	251-660-6333

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

Provider Enumeration Date	:	06/01/2020
Last Update Date	:	03/29/2024

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