Basic Information
Provider Information | |||||||||
NPI: | 1497183818 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WALKER | ||||||||
FirstName: | CONNIE | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 241 SCHOOLHOUSE RD STE 201 | ||||||||
Address2: |   | ||||||||
City: | JOHNSTOWN | ||||||||
State: | PA | ||||||||
PostalCode: | 159043239 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8142665650 | ||||||||
FaxNumber: | 8142665653 | ||||||||
Practice Location | |||||||||
Address1: | 241 SCHOOLHOUSE RD STE 201 | ||||||||
Address2: |   | ||||||||
City: | JOHNSTOWN | ||||||||
State: | PA | ||||||||
PostalCode: | 159043239 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8142665650 | ||||||||
FaxNumber: | 8142665653 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/22/2013 | ||||||||
LastUpdateDate: | 12/12/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/12/2019 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | SP013898 | PA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   | 363L00000X | R207755 | MD | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
ID Information
ID | Type | State | Issuer | Description | 1029341620001 | 05 | PA |   | MEDICAID |