Provider Demographics
NPI:1497722649
Name:WALSH, JODI ELIZABETH (PA C)
Entity Type:Individual
Prefix:MRS
First Name:JODI
Middle Name:ELIZABETH
Last Name:WALSH
Suffix:
Gender:F
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 1:61 BRADLEY ST STE 7
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:CT
Mailing Address - Zip Code:06010-5103
Mailing Address - Country:US
Mailing Address - Phone:860-314-6898
Mailing Address - Fax:860-314-6896
Practice Address - Street 1:61 BRADLEY ST STE 7
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:CT
Practice Address - Zip Code:06010-5103
Practice Address - Country:US
Practice Address - Phone:860-314-6898
Practice Address - Fax:860-314-6896
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001279363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
001279OtherLIC NUMBER
012790OtherCONNECTICARE ID#
012790OtherCONNECTICARE ID#
MW1851989OtherDEA LICENSE
970001812Medicare ID - Type Unspecified