Mia McKenzie Walters, PA-C

Primary specialty

Physician AssistantTaxonomy code 363A00000X

License

2025038815 Issued in MO

Practice address

1455 Village Circle Dr
Glen Carbon, IL 62034-4321

Phone

(618) 477-1810

NPI assigned

May 14, 2025

Last updated

Nov 24, 2025By the provider in NPPES

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in MO

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Specialty

Physician Assistant

Education

Other, 2025

Medicare assignment

May accept Medicare assignment

Practice addresses (Care Compare)

Medicare enrollment (NPD)

Enrolled

Credentials

Physician Assistant

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Cep America, LLC

  dba Vituity

  • Emergency Medicine Physician
  • Saint Louis, MO
  • NPI 1619332046
  Medicare reassignment NPD
• Cep America LLC

  • Emergency Medicine Physician
  • Fort Lauderdale, FL
  • NPI 1700747946
  NPD
• Cep America LLC

  • Emergency Medicine Physician
  • Richmond Heights, MO
  • NPI 1942855366
  NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1747180800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1763942400000",
    "number": "1801687355",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "6420 CLAYTON RD",
            "city": "SAINT LOUIS",
            "state": "MO",
            "postal_code": "631171811",
            "telephone_number": "314-768-8360"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1455 VILLAGE CIRCLE DR",
            "city": "GLEN CARBON",
            "state": "IL",
            "postal_code": "620344321",
            "telephone_number": "618-477-1810"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALTERS",
        "first_name": "MIA",
        "middle_name": "MCKENZIE",
        "credential": "PA-C",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2025-05-14",
        "last_updated": "2025-11-24",
        "certification_date": "2025-11-24",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "MO",
            "license": "2025038815",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Walgreen Co (Walgreens #05665)
• Walgreen Co. (Walgreens #5665)
• Shannon Nicole Walker, PH.D.
• Stephanie Wallace, SLP
• Walmart Inc.
• Elizabeth Warner, MS LCPC
• Raymond K Weber, M.D.
• Ashton Webster
• Hannah Nichole Weid, RBT
• Wellnessone of Glen Carbon, LLC

• Physician Assistant in Glen Carbon, IL
• Providers in Glen Carbon, IL by specialty
• Physician Assistant in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 24, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.