Basic Information
| Provider Information | |||||||||
| NPI: | 1669409652 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALTSAK | ||||||||
| FirstName: | MARTIN | ||||||||
| MiddleName: | JOSEPH | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 625 FAIR OAKS AVE STE 270 | ||||||||
| Address2: | |||||||||
| City: | SOUTH PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 910305801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6263465245 | ||||||||
| FaxNumber: | 6266393005 | ||||||||
| Practice Location | |||||||||
| Address1: | 1900 ATLANTIC AVE | ||||||||
| Address2: | |||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908065502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5625918676 | ||||||||
| FaxNumber: | 8774693631 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2006 | ||||||||
| LastUpdateDate: | 04/20/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | PA14773 | CA | N | Allopathic & Osteopathic Physicians | Family Medicine | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | PA14773 | 01 | CA | MEDI CAL | OTHER | PA14773 | 05 | CA | MEDICAID | PA14773 - WILMINGTON | 05 | CA | MEDICAID | P01272666/DU4032 | 01 | CA | RAILROAD MEDICARE | OTHER |