Basic Information
| Provider Information | |||||||||
| NPI: | 1841258522 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PAE | ||||||||
| FirstName: | WALTER | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 854 | ||||||||
| Address2: | MC A410 | ||||||||
| City: | HERSHEY | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170330854 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002334082 | ||||||||
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| Practice Location | |||||||||
| Address1: | 500 UNIVERSITY DR | ||||||||
| Address2: | |||||||||
| City: | HERSHEY | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170332360 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002334082 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2006 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X | MD021710E | PA | Y | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | 208600000X | MD021710E | PA | N | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0008075510001 | 05 | PA | MEDICAID |