Provider Demographics
NPI:1275681785
Name:WALSH, BRIAN J (PAC)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:J
Last Name:WALSH
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:170 TAMAL VISTA DR
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-1646
Mailing Address - Country:US
Mailing Address - Phone:415-457-0598
Mailing Address - Fax:
Practice Address - Street 1:2351 CLAY ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94115-1931
Practice Address - Country:US
Practice Address - Phone:415-600-6000
Practice Address - Fax:415-600-1298
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA 11923363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant