Provider Demographics
NPI:1619907904
Name:WALSH, MARY C (NP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:C
Last Name:WALSH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1551 E TANGERINE RD
Mailing Address - Street 2:ATTN: MEDICAL STAFF SERVICES
Mailing Address - City:ORO VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85755-6213
Mailing Address - Country:US
Mailing Address - Phone:520-901-3559
Mailing Address - Fax:520-901-3642
Practice Address - Street 1:13101 N ORACLE RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85739-9554
Practice Address - Country:US
Practice Address - Phone:520-901-3559
Practice Address - Fax:520-901-3642
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ031724363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZQ17034Medicare UPIN