| Doctor Name: | RANDALL WALTERS |
| NPI Number: | 1063812782 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | PA |
| License Number: | 5601007119 |
| Business Practice Address: | 5900 Byron Center Ave Sw Wyoming, MI - 495199606 |
| Business Phone Number: | 6162527200 |
| Business Fax Number: | 6162527830 |
| Mailing Address: | 985 Gezon Pkwy Sw, WYOMING |
| State: | MI |
| Postal Code: | 495099563 |
| Phone Number: | 6162527200 |
| Fax Number: | 6162527830 |
| NPI Enumeration Date: | 08/29/2014 |
| NPI Last Update Date: | 01/28/2016 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 363AM0700X |
| License Number: | 5601007119 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | MI |
| Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
| Taxonomy Classification: | Physician Assistant |
| Taxonomy Specialization: | Medical |
| Taxonomy Definition: | |