Provider Demographics
NPI:1669409652
Name:WALTSAK, MARTIN JOSEPH (PA-C)
Entity type:Individual
Prefix:
First Name:MARTIN
Middle Name:JOSEPH
Last Name:WALTSAK
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12942 HARBOR BLVD
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92840-5809
Mailing Address - Country:US
Mailing Address - Phone:714-705-2120
Mailing Address - Fax:
Practice Address - Street 1:12942 HARBOR BLVD
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92840
Practice Address - Country:US
Practice Address - Phone:714-705-2120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA14773207Q00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP01272666/DU4032OtherRAILROAD MEDICARE
CAPA14773 - WILMINGTONMedicaid
CAPA14773OtherMEDI CAL
CAPA14773Medicaid
CAPA14773OtherMEDI CAL
CAPA14773Medicaid
CAAX620XMedicare PIN
CAWPA14773BMedicare PIN
CAP01272666/DU4032OtherRAILROAD MEDICARE
P69286Medicare UPIN
CAAZ620YMedicare PIN
CAWPA14773DMedicare PIN
CAAZ620ZMedicare PIN