Provider Demographics
NPI:1679019467
Name:SOSA, WALTER JR (NP)
Entity type:Individual
Prefix:
First Name:WALTER
Middle Name:
Last Name:SOSA
Suffix:JR
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 COUNTRY CLUB DR
Mailing Address - Street 2:
Mailing Address - City:CALIMESA
Mailing Address - State:CA
Mailing Address - Zip Code:92320-2013
Mailing Address - Country:US
Mailing Address - Phone:909-815-2215
Mailing Address - Fax:
Practice Address - Street 1:11234 ANDERSON ST
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-2804
Practice Address - Country:US
Practice Address - Phone:909-558-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-17
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95005669363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily