Provider Demographics
NPI:1043715006
Name:WALSH, LAURA (MD, PHD)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:WALSH
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:660 SW 39TH ST STE 150
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98057-4912
Mailing Address - Country:US
Mailing Address - Phone:425-690-3483
Mailing Address - Fax:425-690-9083
Practice Address - Street 1:600 SW 39TH ST STE 150
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98057-4911
Practice Address - Country:US
Practice Address - Phone:425-690-3483
Practice Address - Fax:425-690-9083
Is Sole Proprietor?:No
Enumeration Date:2018-03-29
Last Update Date:2022-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.073452207N00000X
WAMD61271877207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2215247Medicaid