Provider Demographics
NPI:1225696842
Name:WALSH, NICHOLAS TYLER (PA-C)
Entity Type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:TYLER
Last Name:WALSH
Suffix:
Gender:M
Credentials:PA-C
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Mailing Address - Street 1:1520 S MAIN ST
Mailing Address - Street 2:STE 2
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45409-2643
Mailing Address - Country:US
Mailing Address - Phone:937-461-5815
Mailing Address - Fax:937-461-2896
Practice Address - Street 1:1653 W CONGRESS PKWY
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3833
Practice Address - Country:US
Practice Address - Phone:888-352-7874
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-29
Last Update Date:2021-11-22
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IL085-007-156363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant