Provider Demographics
NPI:1639137839
Name:WALSH, ROBERT E (PA-C)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:E
Last Name:WALSH
Suffix:
Gender:M
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 1:709 S HARBOR CITY BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-1938
Mailing Address - Country:US
Mailing Address - Phone:321-725-2225
Mailing Address - Fax:321-802-5804
Practice Address - Street 1:709 S HARBOR CITY BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-1938
Practice Address - Country:US
Practice Address - Phone:321-725-2225
Practice Address - Fax:321-802-5804
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2015-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9103429363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL292448000Medicaid
FLU8086YMedicare PIN
FLP00423473Medicare PIN
FLU8086XMedicare PIN
FLP00423468Medicare PIN
FLU8086SMedicare PIN
FL292448000Medicaid
FLU8086YMedicare PIN