Basic Information
| Provider Information | |||||||||
| NPI: | 1992162242 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALLS | ||||||||
| FirstName: | KEN | ||||||||
| MiddleName: | CARLSON | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHD, MPAS, DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12143 DEWAR DR | ||||||||
| Address2: | |||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925054106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3144885943 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10800 MAGNOLIA AVE | ||||||||
| Address2: | |||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925053043 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9513532000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2016 | ||||||||
| LastUpdateDate: | 11/16/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 207R00000X | PTL1723 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1992162242 | 05 | CA | MEDICAID | 1992162242 | 05 | TX | MEDICAID |